Provider Demographics
NPI:1093880866
Name:DEZIEL, DANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:DEZIEL
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 1:1725 W HARRISON
Mailing Address - Street 2:SUITE 810
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3828
Mailing Address - Country:US
Mailing Address - Phone:312-942-6500
Mailing Address - Fax:312-563-2080
Practice Address - Street 1:1725 W HARRISON
Practice Address - Street 2:SUITE 810
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3828
Practice Address - Country:US
Practice Address - Phone:312-942-6500
Practice Address - Fax:312-563-2080
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36061749208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44434Medicare UPIN