Healthcare Provider Details

I. General information

NPI: 1336208842
Provider Name (Legal Business Name): DANIEL L SYVERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11320 MAIN ST SUITE 311
ROSCOE IL
61073-4612
US

IV. Provider business mailing address

PO BOX 311
ROSCOE IL
61073-0311
US

V. Phone/Fax

Practice location:
  • Phone: 815-389-8088
  • Fax: 815-389-3431
Mailing address:
  • Phone: 815-389-8088
  • Fax: 815-389-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number014004040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: