Healthcare Provider Details

I. General information

NPI: 1679735104
Provider Name (Legal Business Name): JEFFREY MICHAEL KSIAZEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD ROAD #519
WINFIELD IL
60190
US

IV. Provider business mailing address

25 N WINFIELD ROAD #519
WINFIELD IL
60190-1222
US

V. Phone/Fax

Practice location:
  • Phone: 630-668-2180
  • Fax:
Mailing address:
  • Phone: 630-668-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036132930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: