Healthcare Provider Details

I. General information

NPI: 1922160365
Provider Name (Legal Business Name): JOLANTA DZIOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE SUTE 509
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

11252 W ALEXANDRIA LN
WESTCHESTER IL
60154-5934
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-2939
  • Fax: 773-792-3214
Mailing address:
  • Phone: 708-562-5132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036055387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: