Provider Demographics
NPI:1114076791
Name:AGATA OCZKO DANGUILAN MD SC
Entity Type:Organization
Organization Name:AGATA OCZKO DANGUILAN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AGATA
Authorized Official - Middle Name:
Authorized Official - Last Name:OCZKO-DANGUILAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-546-5600
Mailing Address - Street 1:2 E ROLLINS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3808
Mailing Address - Country:US
Mailing Address - Phone:847-546-5600
Mailing Address - Fax:847-546-5603
Practice Address - Street 1:2 E ROLLINS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-3808
Practice Address - Country:US
Practice Address - Phone:847-546-5600
Practice Address - Fax:847-546-5603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21368Medicare ID - Type Unspecified
IL142736Medicare UPIN