Provider Demographics
NPI:1083631543
Name:BURDA, DIANA M (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BURDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0001
Mailing Address - Country:US
Mailing Address - Phone:630-545-6016
Mailing Address - Fax:
Practice Address - Street 1:15929 SOUTH BELL ROAD
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6707
Practice Address - Country:US
Practice Address - Phone:708-745-5600
Practice Address - Fax:708-745-5268
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080974Medicaid
ILCJ8704Medicare PIN
IL036080974Medicaid
ILK45737Medicare PIN
E90914Medicare UPIN
IL110232455Medicare PIN
IL704310Medicare PIN