Provider Demographics
NPI:1700846664
Name:DEPAZ, MARY ANNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANNE
Middle Name:
Last Name:DEPAZ
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 1:210 W. MCKINLEY AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-6600
Mailing Address - Fax:217-876-6606
Practice Address - Street 1:210 W. MCKINLEY AVE
Practice Address - Street 2:STE 2
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-6600
Practice Address - Fax:217-876-6606
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1015772085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-101577Medicaid
IL036101577Medicaid
IL036101577Medicaid
ILH16458Medicare UPIN
IL036-101577Medicaid
L78601Medicare PIN