Provider Demographics
NPI:1669479317
Name:CORTLANDT, DEBORAH A (DO)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:A
Last Name:CORTLANDT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 W DEYOUNG ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5896
Mailing Address - Country:US
Mailing Address - Phone:618-998-7600
Mailing Address - Fax:618-998-6680
Practice Address - Street 1:609 W COURT ST
Practice Address - Street 2:SUITE B
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-2633
Practice Address - Country:US
Practice Address - Phone:318-302-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104607207RC0000X
WI52407-21207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64033111Medicaid
IN200302200AMedicaid
H34154Medicare UPIN
IN200302200AMedicaid
KY64033111Medicaid
KY0223318Medicare ID - Type Unspecified
ILL95117Medicare ID - Type Unspecified
IN060063263Medicare ID - Type UnspecifiedRR
IN845900CCMedicare ID - Type Unspecified