Provider Demographics
NPI:1952367351
Name:DERANIAN, MARCUS S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:S
Last Name:DERANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 N ROUTE 121
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9461
Mailing Address - Country:US
Mailing Address - Phone:217-233-3101
Mailing Address - Fax:217-233-3107
Practice Address - Street 1:2442 N ROUTE 121
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9461
Practice Address - Country:US
Practice Address - Phone:217-233-3101
Practice Address - Fax:217-233-3107
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069820152W00000X, 152WC0802X
IL036-069820207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069820Medicaid
IL180033361OtherRAILROAD MEDICARE
IL374073OtherHEALTHLINK
IL49175OtherPERSONAL CARE
IL374073OtherHEALTHLINK
ILK48485Medicare PIN
ILK48479Medicare PIN
IL036069820Medicaid
ILK48481Medicare PIN