Provider Demographics
NPI:1902824915
Name:IWANIK, DIANA O (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:O
Last Name:IWANIK
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 1:7435 W. TALCOTT AVENUE
Mailing Address - Street 2:PRESENCE RMC, RADIOLOGY DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-990-7684
Mailing Address - Fax:773-792-5124
Practice Address - Street 1:7435 W. TALCOTT AVENUE
Practice Address - Street 2:PRESENCE RMC, RADIOLOGY DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-990-7684
Practice Address - Fax:773-792-5124
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360728682085U0001X, 2085R0202X, 2085B0100X, 2085N0700X, 2085N0904X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072868-2Medicaid
IL0001619902OtherBLUE CROSS BLUE SHIELD-IL
IL036072868Medicaid
IL362340Medicare ID - Type UnspecifiedGROUP PROVIDER #
IL0001619902OtherBLUE CROSS BLUE SHIELD-IL
ILE24358Medicare UPIN
ILL36051Medicare PIN
IL036072868Medicaid