Provider Demographics
NPI:1497762587
Name:VAN ZANT, ROBERTA (DO)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:VAN ZANT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:ABBOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:104 E QUEENWOOD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2962
Mailing Address - Country:US
Mailing Address - Phone:309-621-9580
Mailing Address - Fax:309-291-0558
Practice Address - Street 1:104 E QUEENWOOD RD STE 202
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2962
Practice Address - Country:US
Practice Address - Phone:309-621-9580
Practice Address - Fax:309-291-0558
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0351093061Medicaid
IL7215059OtherBCBS PPO
ILIL01U8OtherJOHN DEERE
IL0351093061Medicaid
IL472301OtherHEALTHLINK
ILP00237038OtherRAILROAD MEDICARE
ILIL01U8OtherJOHN DEERE
IL7215059OtherBCBS PPO