Provider Demographics
NPI:1184115339
Name:DEWASWALA, NAKEYA KHOZEMA (MD)
Entity type:Individual
Prefix:
First Name:NAKEYA
Middle Name:KHOZEMA
Last Name:DEWASWALA
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 1:2300 N EDWARD ST STE 2400
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2400
Mailing Address - Fax:217-876-2405
Practice Address - Street 1:2300 N EDWARD ST STE 2400
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-2400
Practice Address - Fax:217-876-2405
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-09-25
Deactivation Date:2019-01-22
Deactivation Code:
Reactivation Date:2019-02-04
Provider Licenses
StateLicense IDTaxonomies
IL036168990207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336126139OtherCS LICENSE