Provider Demographics
NPI:1598721508
Name:MASSIMILIAN, JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MASSIMILIAN
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 1:211 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8309
Mailing Address - Country:US
Mailing Address - Phone:630-655-1055
Mailing Address - Fax:630-655-8966
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:DEPT: ED
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-757-6310
Practice Address - Fax:219-757-6312
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001829A207P00000X
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE55901Medicare UPIN
IN138200IMedicare ID - Type Unspecified