MEDICARE: DR. LISA DEJUANA DANIEL M.D.

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	207V00000X	Obstetrics & Gynecology Physician	036.111457	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

General Provider Information

NPI Number	:	1982632865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA DEJUANA DANIEL M.D.

Provider Business Mailing Address
First Line	:	9119 S EXCHANGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-4225
Country	:	US
Telephone Number	:	773-768-5000
Fax Number	:	773-768-7706

Provider Business Practice Location Address
First Line	:	3223 W 63RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629
Country	:	US
Telephone Number	:	773-768-5000
Fax Number	:	773-778-9593

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	04/21/2023

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