Provider Demographics
NPI:1194709055
Name:NIEBRUGGE, DANIEL J (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:NIEBRUGGE
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:PO BOX 19658
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9658
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4788
Practice Address - Street 1:301 N 8TH ST STE 4A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1013
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4788
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113085208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113085Medicaid
ILK15948Medicare ID - Type Unspecified