Provider Demographics
NPI:1023245693
Name:FAN, DI (MD)
Entity type:Individual
Prefix:
First Name:DI
Middle Name:
Last Name:FAN
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 1:304 WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1900
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:224-235-4652
Practice Address - Street 1:800 BIESTERFIELD RD STE 201B
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-593-8460
Practice Address - Fax:224-235-4652
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123598208D00000X, 208G00000X
DCMD038009208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123598Medicaid
DCMD038009OtherLICENSE
IL036123598Medicaid