Provider Demographics
NPI:1558443721
Name:TROTTA, DANIEL JOHN (OD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JOHN
Last Name:TROTTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9265 W 159TH STREET
Mailing Address - Street 2:
Mailing Address - City:ORLAND HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60477
Mailing Address - Country:US
Mailing Address - Phone:708-349-4360
Mailing Address - Fax:708-349-4359
Practice Address - Street 1:9265 W 159TH STREET
Practice Address - Street 2:
Practice Address - City:ORLAND HILLS
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-349-4360
Practice Address - Fax:708-349-4359
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL645131Medicare ID - Type Unspecified
U38619Medicare UPIN