Healthcare Provider Details

I. General information

NPI: 1104399856
Provider Name (Legal Business Name): TIMOTHY DESMOND MIZDRAK ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2019
Last Update Date: 01/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 S STATE ST # B500
CHICAGO IL
60605-2699
US

IV. Provider business mailing address

1133 S STATE ST # B500
CHICAGO IL
60605-2699
US

V. Phone/Fax

Practice location:
  • Phone: 847-894-6221
  • Fax:
Mailing address:
  • Phone: 847-894-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004715
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: