Healthcare Provider Details

I. General information

NPI: 1457299307
Provider Name (Legal Business Name): DR. DIEP NGUYEN POULOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S WOOD ST
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

820 S WOOD ST MC 675
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2933
  • Fax:
Mailing address:
  • Phone: 312-996-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.088206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: