Healthcare Provider Details

I. General information

NPI: 1508867441
Provider Name (Legal Business Name): DEEPAK P DALIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WAUKEGAN RD SUITE 214
LAKE FOREST IL
60045-2608
US

IV. Provider business mailing address

520 E 22ND ST
LOMBARD IL
60148-6110
US

V. Phone/Fax

Practice location:
  • Phone: 847-298-2192
  • Fax:
Mailing address:
  • Phone: 630-874-2542
  • Fax: 630-874-2642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036051924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: