Provider Demographics
NPI:1184601577
Name:DARMADI, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DARMADI
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 1:1003 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1238
Mailing Address - Country:US
Mailing Address - Phone:618-283-4445
Mailing Address - Fax:618-283-4446
Practice Address - Street 1:1003 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1238
Practice Address - Country:US
Practice Address - Phone:618-283-4445
Practice Address - Fax:618-283-4446
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097600207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097600Medicaid
ILK50872Medicare PIN
G24797Medicare UPIN