Individual
DI FAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
800 BIESTERFIELD RD STE 201B, ELK GROVE VILLAGE, IL 60007-3372
(847) 593-8460
(224) 235-4652
Mailing address
304 WAINWRIGHT DR, NORTHBROOK, IL 60062-1900
(847) 593-8460
(224) 235-4652
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
036123598
IL
208D00000X
General Practice Physician
MD038009
DC
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
036123598
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036123598
—
IL
01
—
MD038009
LICENSE
DC
Enumeration date
06/22/2009
Last updated
11/30/2018
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