Healthcare Provider Details

I. General information

NPI: 1912919259
Provider Name (Legal Business Name): DANIEL MARTIN JURAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 E DIVISION ST
DIAMOND IL
60416
US

IV. Provider business mailing address

114 W WAVERLY ST
MORRIS IL
60450-1422
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-8447
  • Fax: 815-634-8612
Mailing address:
  • Phone: 815-634-0529
  • Fax: 185-634-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036086918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: