Healthcare Provider Details

I. General information

NPI: 1194254367
Provider Name (Legal Business Name): LISA DJINIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA WADOWSKI MD

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10350 HALIGUS RD STE 200B
HUNTLEY IL
60142-9585
US

IV. Provider business mailing address

10350 HALIGUS RD STE 200B
HUNTLEY IL
60142-9585
US

V. Phone/Fax

Practice location:
  • Phone: 847-669-3880
  • Fax: 847-669-2980
Mailing address:
  • Phone: 847-669-3880
  • Fax: 847-669-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020030109
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036167745
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: