Provider Demographics
NPI:1720490741
Name:FATYGA, DIANA MARTA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARTA
Last Name:FATYGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 REMINGTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4707
Mailing Address - Country:US
Mailing Address - Phone:630-914-2898
Mailing Address - Fax:630-914-2469
Practice Address - Street 1:800 AUSTIN ST STE 505
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-733-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125.065916OtherSTATE OF ILLINOIS TEMPORARY LICENSE NUMBER