Provider Demographics
NPI:1235390154
Name:HUERTA DE HATHAWAY, DANIELA (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELA
Middle Name:
Last Name:HUERTA DE HATHAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DAKOTA ST STE A
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3744
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-356-1104
Practice Address - Street 1:650 DAKOTA ST STE A
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-356-1104
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054385207R00000X
IL036127309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01069683OtherRR MEDICARE PTAN
IL036127309Medicaid
IL036127309OtherSTATE LICENSE