Provider Demographics
NPI:1881239564
Name:DAGAN, FEDERICO C JR (PTA)
Entity type:Individual
Prefix:MR
First Name:FEDERICO
Middle Name:C
Last Name:DAGAN
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 CIMARRON DR
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-9107
Mailing Address - Country:US
Mailing Address - Phone:630-267-4802
Mailing Address - Fax:
Practice Address - Street 1:2380 S ELMHURST RD # 100
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-5805
Practice Address - Country:US
Practice Address - Phone:847-786-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008628225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant