Provider Demographics
NPI:1083613293
Name:DECEANNE, ANTHONY V (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:V
Last Name:DECEANNE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 W DETWEILLER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2116
Mailing Address - Country:US
Mailing Address - Phone:309-689-8859
Mailing Address - Fax:
Practice Address - Street 1:5017 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4677
Practice Address - Country:US
Practice Address - Phone:309-691-1589
Practice Address - Fax:309-692-2032
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004489213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004489Medicaid
ILU26359Medicare UPIN
IL016004489Medicaid
IL732422Medicare ID - Type Unspecified
IL0926880001Medicare NSC
IDL18879Medicare UPIN
IL732420Medicare ID - Type Unspecified