Provider Demographics
NPI:1356327514
Name:ENGSTROM, CLARENCE D (MD)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:D
Last Name:ENGSTROM
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 1:3115 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3099
Mailing Address - Country:US
Mailing Address - Phone:847-746-3752
Mailing Address - Fax:847-746-9144
Practice Address - Street 1:3115 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-3099
Practice Address - Country:US
Practice Address - Phone:847-746-3752
Practice Address - Fax:847-746-9144
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036040526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036040526Medicaid
IL036040526Medicaid
IL304920Medicare PIN