Healthcare Provider Details

I. General information

NPI: 1174930887
Provider Name (Legal Business Name): THOMPSON DZIDZA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 01/10/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 W 53RD ST
CHICAGO IL
60609-6109
US

IV. Provider business mailing address

925 W 53RD ST
CHICAGO IL
60609-6109
US

V. Phone/Fax

Practice location:
  • Phone: 773-727-7548
  • Fax:
Mailing address:
  • Phone: 773-727-7548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: