Provider Demographics
NPI:1689886962
Name:ONTIVEROS, EVELENA (MD PHD)
Entity Type:Individual
Prefix:
First Name:EVELENA
Middle Name:
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W MCKINLEY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-5858
Mailing Address - Country:US
Mailing Address - Phone:217-329-3232
Mailing Address - Fax:217-329-1670
Practice Address - Street 1:210 W MCKINLEY AVE
Practice Address - Street 2:STE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-5858
Practice Address - Country:US
Practice Address - Phone:217-879-6600
Practice Address - Fax:217-876-6606
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40470207RH0000X, 207RH0003X, 207R00000X
NY273332207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine