Basic Information
| Provider Information | |||||||||
| NPI: | 1588689285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DANIELE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ODDO | ||||||||
| OtherFirstName: | DANIELE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22285 N PEPPER RD | ||||||||
| Address2: | SUIT 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478826228 | ||||||||
| Practice Location | |||||||||
| Address1: | 22285 N PEPPER RD | ||||||||
| Address2: | SUIT 401 | ||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478826228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036106162 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0361061621 | 05 | IL | MEDICAID |