Healthcare Provider Details

I. General information

NPI: 1063659076
Provider Name (Legal Business Name): ANTON N DIETZEN M.D., D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W HARRISON ST
CHICAGO IL
60612-3825
US

IV. Provider business mailing address

26W171 ROOSEVELT RD
WHEATON IL
60187-6002
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax: 312-942-2867
Mailing address:
  • Phone: 630-909-7000
  • Fax: 630-909-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011314
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD0089692
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036149703
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.069633
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number036149703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: