Provider Demographics
NPI:1134196678
Name:DESAPEREIRA, ELISABETH A V (MD)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:A V
Last Name:DESAPEREIRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1067
Mailing Address - Country:US
Mailing Address - Phone:847-433-0057
Mailing Address - Fax:847-432-2174
Practice Address - Street 1:1117 S MILWAUKEE AVE
Practice Address - Street 2:SUITE B8
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3798
Practice Address - Country:US
Practice Address - Phone:847-816-9180
Practice Address - Fax:847-295-0293
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360499742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049974Medicaid
IL036049974Medicaid
IL748130Medicare ID - Type Unspecified