Provider Demographics
NPI:1548408057
Name:ILLMAN, DWAIN CLARK (MD)
Entity Type:Individual
Prefix:
First Name:DWAIN
Middle Name:CLARK
Last Name:ILLMAN
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:PO BOX 2568
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-2568
Mailing Address - Country:US
Mailing Address - Phone:812-353-3533
Mailing Address - Fax:812-353-3202
Practice Address - Street 1:811 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2251
Practice Address - Country:US
Practice Address - Phone:812-353-3533
Practice Address - Fax:812-353-3204
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027208207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND94630Medicare UPIN