Provider Demographics
NPI:1952414708
Name:RAIS DANA, JALAL (MD)
Entity Type:Individual
Prefix:MR
First Name:JALAL
Middle Name:
Last Name:RAIS DANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062
Mailing Address - Country:US
Mailing Address - Phone:847-509-9671
Mailing Address - Fax:847-509-9671
Practice Address - Street 1:8780 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714
Practice Address - Country:US
Practice Address - Phone:847-296-6706
Practice Address - Fax:847-799-1679
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36 090842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
003011Medicare UPIN