Basic Information
| Provider Information | |||||||||
| NPI: | 1356446322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE SAGUN | ||||||||
| FirstName: | EVANGELINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 S GEAR AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526551679 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 S GEAR AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526551679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197681000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 036097387 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 32913278 | 01 | CHAMPUS | OTHER | P00047449 | 01 | RAILROAD MEDICARE | OTHER | 009847 | 01 | HEALTH ALLIANCE | OTHER | 1922250 | 01 | IL | BCBS IL | OTHER | 036097387 | 05 | IL | MEDICAID |