Provider Demographics
NPI:1518131903
Name:RUPP, DEMETRA VLAGOS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRA
Middle Name:VLAGOS
Last Name:RUPP
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 1:302 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4209
Mailing Address - Country:US
Mailing Address - Phone:630-208-6775
Mailing Address - Fax:630-208-7937
Practice Address - Street 1:302 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-208-6775
Practice Address - Fax:630-208-7937
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115634207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL206147110OtherMEDICARE PTAN (INDIVIDUAL)
ILCE8792OtherRAILROAD MEDICARE PTAN (GROUP)
IL201557001OtherMEDICARE PTAN
ILP01090235OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)
IL036-115634OtherIL LICENSE #
IL036115634Medicaid