Provider Demographics
NPI:1952532426
Name:ANDRE T DEJEAN /DEJEAN WELLNESS
Entity Type:Organization
Organization Name:ANDRE T DEJEAN /DEJEAN WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEJEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-620-9864
Mailing Address - Street 1:9040 S MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3811
Mailing Address - Country:US
Mailing Address - Phone:773-620-9864
Mailing Address - Fax:866-261-3402
Practice Address - Street 1:9040 S MERRILL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3811
Practice Address - Country:US
Practice Address - Phone:773-620-9864
Practice Address - Fax:866-261-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-02
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1639140700OtherNPI
IL036098449Medicaid