Provider Demographics
NPI:1558694059
Name:DAIGLE, JEREMY DWAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DWAINE
Last Name:DAIGLE
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-2600
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:4220 W 95TH ST STE 210
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2793
Practice Address - Country:US
Practice Address - Phone:312-949-4200
Practice Address - Fax:708-423-1899
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130545208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics