Provider Demographics
NPI:1417950783
Name:DEVASSY, ELSY A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELSY
Middle Name:A
Last Name:DEVASSY
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 1:16612 W 159TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8006
Mailing Address - Country:US
Mailing Address - Phone:815-588-3900
Mailing Address - Fax:815-588-1414
Practice Address - Street 1:16612 W 159TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8006
Practice Address - Country:US
Practice Address - Phone:815-588-3900
Practice Address - Fax:815-588-1414
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063297Medicaid
IL036063297Medicaid