Provider Demographics
NPI:1922187756
Name:TOMASIAN, DOUGLAS A (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:TOMASIAN
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 1:350 E CONGRESS PKWY STE E
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6284
Mailing Address - Country:US
Mailing Address - Phone:815-477-8900
Mailing Address - Fax:815-477-7160
Practice Address - Street 1:350 E CONGRESS PKWY STE E
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6284
Practice Address - Country:US
Practice Address - Phone:815-477-8900
Practice Address - Fax:815-477-7160
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096363207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05625392OtherBC & BS OF ILLINOIS
ILP00272058OtherRAILROAD MC
IL036096363OtherSTATE LICENSE
IL036096363Medicaid
ILK20404Medicare ID - Type Unspecified
ILK20403Medicare ID - Type Unspecified
ILP00272058OtherRAILROAD MC