Provider Demographics
NPI:1518306489
Name:LYGRISSE, DANIEL RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:RICHARD
Last Name:LYGRISSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1271
Mailing Address - Country:US
Mailing Address - Phone:217-864-2665
Mailing Address - Fax:
Practice Address - Street 1:104 E ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:MT ZION
Practice Address - State:IL
Practice Address - Zip Code:62549-1271
Practice Address - Country:US
Practice Address - Phone:217-864-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013284208600000X
MI5101020360390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH601150OtherMEDICARE
OH0282518Medicaid