Provider Demographics
NPI:1659786150
Name:TABOR, DIANA (DPM)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:TABOR
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:PANEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE STE 240
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-510-6929
Practice Address - Fax:630-355-3257
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005675213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1659786150Medicaid