Healthcare Provider Details

I. General information

NPI: 1992190052
Provider Name (Legal Business Name): DANIEL DIACZOK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2015
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

4012 W LE MONT BLVD
MEQUON WI
53092-5227
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number73226-21
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number73226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: