Basic Information
| Provider Information | |||||||||
| NPI: | 1497283774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIATLOS-DEAK | ||||||||
| FirstName: | LARISA | ||||||||
| MiddleName: | GEORGY | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEAK | ||||||||
| OtherFirstName: | LARISA | ||||||||
| OtherMiddleName: | RUDICA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4965 E LOST BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625215139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178645531 | ||||||||
| FaxNumber: | 2178642449 | ||||||||
| Practice Location | |||||||||
| Address1: | 4965 E LOST BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625215139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178645531 | ||||||||
| FaxNumber: | 2178642449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2017 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036153610 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.