Provider Demographics
NPI:1134308612
Name:DANIEL JURAK D O S C
Entity Type:Organization
Organization Name:DANIEL JURAK D O S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:JURAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-634-8447
Mailing Address - Street 1:935 E DIVISION
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1346
Mailing Address - Country:US
Mailing Address - Phone:815-634-8447
Mailing Address - Fax:815-634-8612
Practice Address - Street 1:935 E DIVISION
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1346
Practice Address - Country:US
Practice Address - Phone:815-634-0529
Practice Address - Fax:815-634-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF85567Medicare UPIN