Individual
MIRCEA TUDOR IACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
25 N WINFIELD RD, WINFIELD, IL 60190-1295
(630) 933-4056
(630) 933-4057
Mailing address
25 N WINFIELD RD, WINFIELD, IL 60190-1295
(630) 933-4056
(630) 933-4057
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
036-113093
IL
2084N0400X
Neurology Physician
036113093
IL
2084V0102X
Vascular Neurology Physician
Primary
036113093
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036113093
—
IL
01
—
1635130
BCBS
IL
01
—
206147084
MEDICARE PTAN (INDIVIDUAL)
IL
01
—
CE8792
RAILROAD MEDICARE PTAN (GROUP)
IL
01
—
P01090248
RAILROAD MEDICARE PTAN (INDIVIDUAL)
IL
Enumeration date
05/18/2006
Last updated
12/03/2012
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