Provider Demographics
NPI:1851399976
Name:HARTMAN, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:HARTMAN
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 1:201 BAILEY LANE
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-0000
Mailing Address - Country:US
Mailing Address - Phone:618-439-3161
Mailing Address - Fax:618-439-4049
Practice Address - Street 1:201 BAILEY LANE
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-0000
Practice Address - Country:US
Practice Address - Phone:618-439-3161
Practice Address - Fax:618-439-4049
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014269207Q00000X
IL036111331207Q00000X
IL2004014269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111331Medicaid
ILI15206Medicare UPIN
ILK22097Medicare ID - Type Unspecified
I15206Medicare UPIN