Provider Demographics
NPI:1487008389
Name:DISSEN, MOSHE
Entity Type:Individual
Prefix:
First Name:MOSHE
Middle Name:
Last Name:DISSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 N HALSTED ST STE 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2612
Mailing Address - Country:US
Mailing Address - Phone:773-871-4409
Mailing Address - Fax:312-649-9653
Practice Address - Street 1:1460 N HALSTED ST STE 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2612
Practice Address - Country:US
Practice Address - Phone:708-763-1222
Practice Address - Fax:312-649-9653
Is Sole Proprietor?:No
Enumeration Date:2016-04-17
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149851207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine