Healthcare Provider Details

I. General information

NPI: 1447246822
Provider Name (Legal Business Name): DANIEL C DESIMONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13755 CICERO AVE
CRESTWOOD IL
60418-1824
US

IV. Provider business mailing address

13755 CICERO AVE
CRESTWOOD IL
60418-1824
US

V. Phone/Fax

Practice location:
  • Phone: 708-972-7642
  • Fax: 708-925-9179
Mailing address:
  • Phone: 708-972-7642
  • Fax: 708-925-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-078524
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: