Provider Demographics
NPI:1174508246
Name:VICENCIO, DANIEL P (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:P
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 S MICHIGAN AVE
Mailing Address - Street 2:B-390
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2333
Mailing Address - Country:US
Mailing Address - Phone:312-567-6691
Mailing Address - Fax:312-328-7702
Practice Address - Street 1:2525 S MICHIGAN AVE
Practice Address - Street 2:B-390
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2333
Practice Address - Country:US
Practice Address - Phone:312-567-6691
Practice Address - Fax:312-328-7702
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL036088743Medicaid
IL036088743Medicaid
IL296150Medicare ID - Type UnspecifiedGROUP 950150