Provider Demographics
NPI:1982632865
Name:DANIEL, LISA DEJUANA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DEJUANA
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9119 S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4225
Mailing Address - Country:US
Mailing Address - Phone:773-768-5000
Mailing Address - Fax:773-768-7706
Practice Address - Street 1:3223 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:773-768-5000
Practice Address - Fax:773-778-9593
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.111457207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111457Medicaid