Provider Demographics
NPI:1821070517
Name:TRACHTENBERG, JEFFREY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:TRACHTENBERG
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 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-464-1722
Mailing Address - Fax:217-464-1717
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-1722
Practice Address - Fax:217-464-1717
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361038452086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI4811OtherMEDICARE TRAVELERS
L83295Medicare PIN
CI4811OtherMEDICARE TRAVELERS