Basic Information
| Provider Information | |||||||||
| NPI: | 1699734186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONAGH | ||||||||
| FirstName: | DESMOND | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 BUTTERFIELD RD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605157915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252768 | ||||||||
| FaxNumber: | 6307252783 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 NATIONS DR | ||||||||
| Address2: | SUITE #207 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600319164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472059900 | ||||||||
| FaxNumber: | 8472059905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036046231 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 202K00000X | 036-046231 | IL | N | Allopathic & Osteopathic Physicians | Phlebology |
ID Information
| ID | Type | State | Issuer | Description | 01622308 | 01 | IL | BXBS | OTHER |