Provider Demographics
NPI:1447246822
Name:DESIMONE, DANIEL C (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:C
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13755 CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1824
Mailing Address - Country:US
Mailing Address - Phone:708-972-7642
Mailing Address - Fax:708-925-9179
Practice Address - Street 1:13755 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-1824
Practice Address - Country:US
Practice Address - Phone:708-972-7642
Practice Address - Fax:708-925-9179
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-078524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200998470Medicaid
IN200998470Medicaid
ILE30020Medicare UPIN
IL036-078-524Medicaid