Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | IL |
NPI | 1194804245 |
---|---|
Provider Name | Dr. Effie Dis |
First Address | Glenview, IL 60026-1529 |
Second Address | Wheeling, IL 60090-3107 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D14902 | (02) | IL |