Provider Demographics
NPI:1720548712
Name:SZPARA, ETHAN MACKENZIE (DO)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:MACKENZIE
Last Name:SZPARA
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 1:41W410 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-8366
Mailing Address - Country:US
Mailing Address - Phone:630-945-7728
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125073981207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program