Provider Demographics
NPI:1215482567
Name:DE JONG, DAVID JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:DE JONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:JOHN
Other - Last Name:DE JONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:226 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5716
Mailing Address - Country:US
Mailing Address - Phone:312-909-2116
Mailing Address - Fax:312-915-0015
Practice Address - Street 1:226 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5716
Practice Address - Country:US
Practice Address - Phone:312-909-2116
Practice Address - Fax:312-915-0015
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.053269208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice