Provider Demographics
NPI:1891969549
Name:DEKALB MEDICAL CLINIC,INC
Entity type:Organization
Organization Name:DEKALB MEDICAL CLINIC,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VASANTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:352-857-9150
Mailing Address - Street 1:2128 MIDLANDS CT
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3199
Mailing Address - Country:US
Mailing Address - Phone:815-756-1434
Mailing Address - Fax:
Practice Address - Street 1:2128 MIDLANDS CT
Practice Address - Street 2:SUITE 106
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3199
Practice Address - Country:US
Practice Address - Phone:815-756-1434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-099204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty