Provider Demographics
NPI:1326120999
Name:DORMITORIO, AGUSTIN DEQUINA (MD)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:DEQUINA
Last Name:DORMITORIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 HYDE PARK LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-1622
Mailing Address - Country:US
Mailing Address - Phone:773-578-1464
Mailing Address - Fax:
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-271-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42415Medicare UPIN
ILK23088Medicare ID - Type Unspecified