Provider Demographics
NPI:1104922285
Name:FABRIZIUS, DIANE D (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:D
Last Name:FABRIZIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 E SCHILLER ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:331-221-0000
Mailing Address - Fax:331-221-2312
Practice Address - Street 1:172 E SCHILLER ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:331-221-0000
Practice Address - Fax:331-221-2312
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-075602207R00000X
IL036075602207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-075602Medicaid
ILC41780Medicare UPIN
ILP06050Medicare PIN