Provider Demographics
NPI:1639379381
Name:GERSHON, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GERSHON
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 1:350 S WAUKEGAN RD STE 150
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5239
Mailing Address - Country:US
Mailing Address - Phone:847-475-2273
Mailing Address - Fax:312-926-2185
Practice Address - Street 1:350 S WAUKEGAN RD STE 150
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5239
Practice Address - Country:US
Practice Address - Phone:847-475-2273
Practice Address - Fax:312-926-2185
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122862207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125047539Other125047539