Provider Demographics
NPI:1164518320
Name:VITTUM, DANIEL W (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:VITTUM
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 1:1800 HARLEM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1468
Mailing Address - Country:US
Mailing Address - Phone:708-783-9800
Mailing Address - Fax:708-783-9810
Practice Address - Street 1:1800 HARLEM AVE STE A
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1468
Practice Address - Country:US
Practice Address - Phone:708-783-9800
Practice Address - Fax:773-780-9810
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine