Provider Demographics
NPI:1205084431
Name:DASTYCH, THEODORE E (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:E
Last Name:DASTYCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-4841
Mailing Address - Country:US
Mailing Address - Phone:815-741-1126
Mailing Address - Fax:
Practice Address - Street 1:3237 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-4841
Practice Address - Country:US
Practice Address - Phone:815-741-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38302Medicare UPIN