Healthcare Provider Details

I. General information

NPI: 1295802882
Provider Name (Legal Business Name): PAUL ANTONY PANZICA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19621 LA GRANGE RD
MOKENA IL
60448-9360
US

IV. Provider business mailing address

19621 S LA GRANGE RD
MOKENA IL
60448-9360
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-8380
  • Fax: 708-478-3036
Mailing address:
  • Phone: 708-478-8380
  • Fax: 708-478-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036095398
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036095398
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: