Provider Demographics
NPI:1659719433
Name:MERDEGIA, DODA BARTOLABAC
Entity type:Individual
Prefix:MRS
First Name:DODA
Middle Name:BARTOLABAC
Last Name:MERDEGIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 WHITEWATER DR APT 105
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-7908
Mailing Address - Country:US
Mailing Address - Phone:815-295-3923
Mailing Address - Fax:
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-933-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist