Provider Demographics
NPI:1417016205
Name:DAVID, JACQUELINE DEBORAH (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DEBORAH
Last Name:DAVID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:909 DAVIS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3645
Practice Address - Country:US
Practice Address - Phone:847-866-3700
Practice Address - Fax:847-866-5436
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-066565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13337Medicare UPIN