Provider Demographics
NPI:1336208842
Name:SYVERSON, DANIEL L (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:SYVERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-0311
Mailing Address - Country:US
Mailing Address - Phone:815-389-8088
Mailing Address - Fax:815-389-3431
Practice Address - Street 1:11320 MAIN ST
Practice Address - Street 2:SUITE 311
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-4612
Practice Address - Country:US
Practice Address - Phone:815-389-8088
Practice Address - Fax:815-389-3431
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL014004040213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004040Medicaid
ILT38617Medicare UPIN
IL016004040Medicaid