Basic Information
| Provider Information | |||||||||
| NPI: | 1831399583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANIEL | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5019 N MOZART ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738788200 | ||||||||
| FaxNumber: | 7732934197 | ||||||||
| Practice Location | |||||||||
| Address1: | 6225 W TOUHY AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606461105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736312223 | ||||||||
| FaxNumber: | 7736315607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036125559 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 125052971 | 01 | IL | 125052971 | OTHER |