Provider Demographics
NPI:1962400556
Name:DANIELS, CRYSTAL BANKS (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:BANKS
Last Name:DANIELS
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 1:228 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2889
Mailing Address - Country:US
Mailing Address - Phone:630-835-1430
Mailing Address - Fax:630-835-1433
Practice Address - Street 1:228 E LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2889
Practice Address - Country:US
Practice Address - Phone:630-835-1430
Practice Address - Fax:630-835-1433
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483489Medicaid
MI4483489Medicaid
MION68270001Medicare ID - Type Unspecified