Provider Demographics
NPI:1710074653
Name:FONDAHN, DEAN (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:FONDAHN
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 5009
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-5009
Mailing Address - Country:US
Mailing Address - Phone:615-221-3642
Mailing Address - Fax:615-371-4600
Practice Address - Street 1:101 E MILLER RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1252
Practice Address - Country:US
Practice Address - Phone:815-625-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066790208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL012794OtherHEALTH ALLIANCE MEDICAL
IL036066790Medicaid
IL9815737OtherBLUE CROSS BLUE SHIELD
340007312OtherRAILROAD
IL9815737OtherBLUE CROSS BLUE SHIELD
ILP00521Medicare PIN
IL036066790Medicaid