Provider Demographics
NPI:1366424061
Name:MAIBENCO, DOUGLAS CRAIG (MD PHD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CRAIG
Last Name:MAIBENCO
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3809
Mailing Address - Country:US
Mailing Address - Phone:217-329-1000
Mailing Address - Fax:217-329-1055
Practice Address - Street 1:1730 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-329-1000
Practice Address - Fax:217-329-1055
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098825208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098825Medicaid
CI8411OtherMEDICARE TRAVELERS
G14558Medicare UPIN