Healthcare Provider Details

I. General information

NPI: 1710971700
Provider Name (Legal Business Name): DANIEL R WYNN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 LAKE COOK RD SUITE 601
NORTHBROOK IL
60062-1447
US

IV. Provider business mailing address

1535 LAKE COOK RD SUITE 601
NORTHBROOK IL
60062-1447
US

V. Phone/Fax

Practice location:
  • Phone: 847-509-0270
  • Fax: 847-509-0273
Mailing address:
  • Phone: 847-509-0270
  • Fax: 847-509-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036076784
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036-076784
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number036-076784
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number036076784
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: