Provider Demographics
NPI:1316963689
Name:DERUS, CHARLES L (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DERUS
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 1:1870 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4356
Mailing Address - Country:US
Mailing Address - Phone:630-859-6700
Mailing Address - Fax:
Practice Address - Street 1:1870 W GALENA BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4356
Practice Address - Country:US
Practice Address - Phone:630-859-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00928OtherINDIVIDUAL MEDICARE #
ILL74630Medicare ID - Type Unspecified
D77217Medicare UPIN
P00928OtherINDIVIDUAL MEDICARE #