Provider Demographics
NPI:1912919259
Name:JURAK, DANIEL MARTIN (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARTIN
Last Name:JURAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W WAVERLY ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1422
Mailing Address - Country:US
Mailing Address - Phone:815-634-0529
Mailing Address - Fax:185-634-0127
Practice Address - Street 1:935 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:DIAMOND
Practice Address - State:IL
Practice Address - Zip Code:60416
Practice Address - Country:US
Practice Address - Phone:815-634-8447
Practice Address - Fax:815-634-8612
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003220011OtherILLINOIS BC/BS
IL036086918Medicaid