Provider Demographics
NPI:1477717247
Name:DEAN, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:DEAN
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 1:210 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2497
Mailing Address - Country:US
Mailing Address - Phone:309-647-5240
Mailing Address - Fax:309-649-5128
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2497
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:309-649-5128
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-128312207P00000X
NE5836207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361283121Medicaid
ILP00960789OtherRRMCARE THRU CES
ILP00984806OtherRRMCARE THRU GES
IL0361283122Medicaid
IL210426011Medicare PIN
ILP00960789OtherRRMCARE THRU CES