Healthcare Provider Details

I. General information

NPI: 1720490741
Provider Name (Legal Business Name): DIANA MARTA FATYGA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 AUSTIN ST STE 505
EVANSTON IL
60202-3439
US

IV. Provider business mailing address

1000 REMINGTON BLVD STE 100
BOLINGBROOK IL
60440-4707
US

V. Phone/Fax

Practice location:
  • Phone: 847-733-1495
  • Fax:
Mailing address:
  • Phone: 630-914-2898
  • Fax: 630-914-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036143778
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: