Provider Demographics
NPI:1316911472
Name:BISTRICEANU, GRAZIELLA I (MD)
Entity type:Individual
Prefix:DR
First Name:GRAZIELLA
Middle Name:I
Last Name:BISTRICEANU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRAZIELLA
Other - Middle Name:I
Other - Last Name:IACOVENCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1925 HUNTLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-9301
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:847-428-7425
Practice Address - Street 1:1925 HUNTLEY RD
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-9301
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-428-7425
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112686207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361126861Medicaid
ILI31502Medicare UPIN
IL0361126861Medicaid