Provider Demographics
NPI:1578565701
Name:COSTERISAN, DENNIS D (DO)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:D
Last Name:COSTERISAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4665
Mailing Address - Country:US
Mailing Address - Phone:217-877-9117
Mailing Address - Fax:217-728-2580
Practice Address - Street 1:320 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4665
Practice Address - Country:US
Practice Address - Phone:217-877-9117
Practice Address - Fax:217-877-3078
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080105720OtherRAILROAD MEDICARE
IL178026OtherHEALTHLINK
IL0360710252Medicaid
IL0007005197OtherBLUE CROSS BLUE SHIELD
ILF20462Medicare UPIN
IL080105720OtherRAILROAD MEDICARE
IL0360710252Medicaid