Provider Demographics
NPI:1063659076
Name:DIETZEN, ANTON N (MD, DC)
Entity Type:Individual
Prefix:DR
First Name:ANTON
Middle Name:N
Last Name:DIETZEN
Suffix:
Gender:M
Credentials:MD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6002
Mailing Address - Country:US
Mailing Address - Phone:630-909-7000
Mailing Address - Fax:630-909-7002
Practice Address - Street 1:1750 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3825
Practice Address - Country:US
Practice Address - Phone:312-942-6510
Practice Address - Fax:312-942-2867
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011314111N00000X
MDD0089692208100000X
IL036149703208100000X, 2081P0010X
IL125.069633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No111N00000XChiropractic ProvidersChiropractor
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208600000XAllopathic & Osteopathic PhysiciansSurgery