Basic Information
| Provider Information | |||||||||
| NPI: | 1649451352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANTZEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096553410 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 NE GLEN OAK AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616033105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096553453 | ||||||||
| FaxNumber: | 3096553410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301097945 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 5841 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 4301097945 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 036.138159 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.