Provider Demographics
NPI:1982657904
Name:DEORAS, MUKUND P (MD)
Entity Type:Individual
Prefix:
First Name:MUKUND
Middle Name:P
Last Name:DEORAS
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:PO BOX 9518
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-9518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-344-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-05-12
Deactivation Date:2010-03-25
Deactivation Code:
Reactivation Date:2010-06-23
Provider Licenses
StateLicense IDTaxonomies
IL036053626207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360536262Medicaid
ILC47256Medicare UPIN
IL0360536262Medicaid