Provider Demographics
NPI:1265798060
Name:GRIFFIN, DANA M (MD)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:M
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:MONDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 WARWICK WAY
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5661
Practice Address - Country:US
Practice Address - Phone:262-321-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.061562207N00000X
WI67748207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100072198Medicaid