Provider Demographics
NPI:1740273499
Name:GAUTHIER, DANIEL D (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:D
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E COUNTYLINE RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2178
Mailing Address - Country:US
Mailing Address - Phone:815-786-2722
Mailing Address - Fax:815-786-6840
Practice Address - Street 1:1 E COUNTYLINE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2178
Practice Address - Country:US
Practice Address - Phone:815-786-2722
Practice Address - Fax:815-786-6840
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1921614OtherBC/BS
IL036082774Medicaid
IL036082774Medicaid
IL1921614OtherBC/BS