MEDICARE: DR. DEEPAK P DALIA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	036051924	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	202926	OTHER	IL	GROUP PTAN

General Provider Information

NPI Number	:	1508867441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEEPAK P DALIA MD

Provider Business Mailing Address
First Line	:	520 E 22ND ST
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-6110
Country	:	US
Telephone Number	:	630-874-2542
Fax Number	:	630-874-2642

Provider Business Practice Location Address
First Line	:	840 S WAUKEGAN RD
Second Line	:	SUITE 214
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2608
Country	:	US
Telephone Number	:	847-298-2192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	01/19/2015

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