Provider Demographics
NPI:1477547974
Name:POLK, DANIEL H (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:POLK
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 1:12430 S POST RD
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-2554
Mailing Address - Country:US
Mailing Address - Phone:708-923-0969
Mailing Address - Fax:
Practice Address - Street 1:12430 S POST RD
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-2554
Practice Address - Country:US
Practice Address - Phone:708-923-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0935932080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093593Medicaid