Healthcare Provider Details

I. General information

NPI: 1508951351
Provider Name (Legal Business Name): ANDREW QUINBY DEFUNIAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S CALIFORNIA AVE MED/SURG OFFICE
CHICAGO IL
60608-5107
US

IV. Provider business mailing address

5245 N MAGNOLIA AVE
CHICAGO IL
60640-2202
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-7488
  • Fax: 773-869-3578
Mailing address:
  • Phone: 773-869-7488
  • Fax: 773-869-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-107970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: