Provider Demographics
NPI:1386733145
Name:DEOSKAR, UDAY L (MD)
Entity type:Individual
Prefix:DR
First Name:UDAY
Middle Name:L
Last Name:DEOSKAR
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 1:2103 E WASHINGTON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:309-663-5810
Mailing Address - Fax:309-663-5828
Practice Address - Street 1:2103 E WASHINGTON ST STE 2C
Practice Address - Street 2:SENIOR HEALTH & GERIATRICS OF CENTRAL IL
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-663-5810
Practice Address - Fax:309-663-5828
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054887207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005728058OtherBLUE SHIELD
IL036054887Medicaid
IL036054887Medicaid
ILK04772Medicare PIN