Provider Demographics
NPI:1790759009
Name:BRAZDZIUNAS, DANA (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BRAZDZIUNAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:BOX 16
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2605
Mailing Address - Country:US
Mailing Address - Phone:312-227-6720
Mailing Address - Fax:312-227-9418
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:BOX 16
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2605
Practice Address - Country:US
Practice Address - Phone:312-227-6720
Practice Address - Fax:312-227-9418
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360748532080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36074853Medicaid
E57245Medicare UPIN