Provider Demographics
NPI:1659371573
Name:DIMOPOULOS, JOAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:DIMOPOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JOAN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:458 N RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2218
Mailing Address - Country:US
Mailing Address - Phone:630-782-0135
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30548207P00000X
IL036099835207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ709967Medicaid
AZG91274Medicare UPIN
AZ709967Medicaid