Provider Demographics
NPI:1073301206
Name:DESHEROW, ELLISS (DO)
Entity type:Individual
Prefix:
First Name:ELLISS
Middle Name:
Last Name:DESHEROW
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38W155 HENRICKSEN RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-5471
Mailing Address - Country:US
Mailing Address - Phone:224-678-4061
Mailing Address - Fax:
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6332
Practice Address - Country:US
Practice Address - Phone:580-355-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program