Provider Demographics
NPI:1508867441
Name:DALIA, DEEPAK P (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:P
Last Name:DALIA
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 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-874-2542
Mailing Address - Fax:630-874-2642
Practice Address - Street 1:840 S WAUKEGAN RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2608
Practice Address - Country:US
Practice Address - Phone:847-298-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360519242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051924Medicaid
IL202926OtherGROUP PTAN
IL036051924Medicaid
ILK49018Medicare PIN