Provider Demographics
NPI:1710305560
Name:DEEKEN DRAISEY, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:DEEKEN DRAISEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:DEEKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-6868
Mailing Address - Fax:
Practice Address - Street 1:303 E CHICAGO AVE # 3140W127
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4296
Practice Address - Country:US
Practice Address - Phone:312-503-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-30
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036144258207ZP0102X
390200000X
ILX207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1710305560Medicaid