Provider Demographics
NPI:1215007877
Name:NISSAN, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:NISSAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAOUD
Other - Middle Name:E
Other - Last Name:NISSAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5140 N CALIFORNIA
Mailing Address - Street 2:SUITE 550
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:773-728-8800
Mailing Address - Fax:773-728-0117
Practice Address - Street 1:5140 N CALIFORNIA
Practice Address - Street 2:SUITE 550
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-728-8800
Practice Address - Fax:773-728-0117
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062588207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062588Medicaid
IL31601661OtherBCBS
IL31601661OtherBCBS