Healthcare Provider Details

I. General information

NPI: 1043491426
Provider Name (Legal Business Name): DAVID EUGENE STIASNY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE 601
CHICAGO IL
60625-8564
US

IV. Provider business mailing address

5215 N CALIFORNIA AVE STE 601
CHICAGO IL
60625-8564
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-3627
  • Fax: 773-989-1669
Mailing address:
  • Phone: 773-878-3627
  • Fax: 773-989-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301090550
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036132909
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: