Provider Demographics
NPI:1861443947
Name:ROOZEBOOM, DAVID R (APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:ROOZEBOOM
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-933-6675
Mailing Address - Fax:630-933-2614
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-933-6675
Practice Address - Fax:630-933-2614
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28152566A367500000X
IL209001543367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7066465OtherAETNA
IN200373590AMedicaid
IN000000248211OtherANTHEM BCBS
IN200373590AMedicaid