Provider Demographics
NPI:1134749294
Name:IZEWSKI, DANIEL JOSEPH
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:IZEWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 ELM ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2119
Mailing Address - Country:US
Mailing Address - Phone:639-391-8322
Mailing Address - Fax:
Practice Address - Street 1:3908 ELM ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2119
Practice Address - Country:US
Practice Address - Phone:639-391-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-19
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008027261QU0200X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program