Provider Demographics
NPI:1760976328
Name:JOSEPH, DEEPA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:ELIZABETH
Last Name:JOSEPH
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 1:611 W. PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 HURST DR STE 130
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9200
Practice Address - Country:US
Practice Address - Phone:217-258-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072653390200000X
IL036155220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program