Healthcare Provider Details

I. General information

NPI: 1699701342
Provider Name (Legal Business Name): ROSE DIAKOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 WICKER AVE FL 2
SAINT JOHN IN
46373-9487
US

IV. Provider business mailing address

1460 N. HALSTED SUITE 503
CHICAGO IL
60639-6158
US

V. Phone/Fax

Practice location:
  • Phone: 219-226-2236
  • Fax:
Mailing address:
  • Phone: 773-472-1444
  • Fax: 312-787-4424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036081535
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01082758A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: