Provider Demographics
NPI:1447273883
Name:DANIEL, ELIE CHUKRI (D P M)
Entity type:Individual
Prefix:DR
First Name:ELIE
Middle Name:CHUKRI
Last Name:DANIEL
Suffix:
Gender:M
Credentials:D P M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-0147
Mailing Address - Country:US
Mailing Address - Phone:815-875-2643
Mailing Address - Fax:815-539-3824
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:SUITE 204
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-875-2643
Practice Address - Fax:815-876-2353
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004155213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004155Medicaid
IL371225142OtherTAX ID #
ILT38904Medicare UPIN
IL775240Medicare PIN