Provider Demographics
NPI:1013128222
Name:DEWAR, JAMES DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DANIEL
Last Name:DEWAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WOODBROOK CT
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-4779
Mailing Address - Country:US
Mailing Address - Phone:309-922-1006
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049248207R00000X
MN56304207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120002Medicaid
ILCA4079OtherRR MEDICARE GROUP PTAN
ILP00617111OtherRR MEDICARE GROUP MEMBER PTAN
IL809840OtherMEDICARE GROUP
ILCA4079OtherRR MEDICARE GROUP PTAN
ILR01433Medicare PIN