Provider Demographics
NPI:1386773604
Name:TAWJAREON, PREECHA (MD)
Entity type:Individual
Prefix:DR
First Name:PREECHA
Middle Name:
Last Name:TAWJAREON
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 1:815 W MAIN ST
Mailing Address - Street 2:PO BOX 875
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-0875
Mailing Address - Country:US
Mailing Address - Phone:618-548-2843
Mailing Address - Fax:618-548-2896
Practice Address - Street 1:815 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-0875
Practice Address - Country:US
Practice Address - Phone:618-548-2843
Practice Address - Fax:618-548-2896
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP04756OtherFLORA PIN #
IL0006115210OtherBLUECROSS BLUESHIELD
ILL06343OtherSALEM PIN #
ILCF1003OtherRAILROAD MEDICARE
ILCF1003OtherRAILROAD MEDICARE
ILL06343OtherSALEM PIN #