1902112535 NPI number — FABIOLA MARIA DEL CARMEN ESPINOZA MD

Table of content: FABIOLA MARIA DEL CARMEN ESPINOZA MD (NPI 1902112535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902112535 NPI number — FABIOLA MARIA DEL CARMEN ESPINOZA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESPINOZA
Provider First Name:
FABIOLA
Provider Middle Name:
MARIA DEL CARMEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902112535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MC CLINTOCK DRIVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-0872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-220-6432
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 W COURT ST
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-3664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-220-6432
Provider Business Practice Location Address Fax Number:
630-734-4715
Provider Enumeration Date:
08/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  036129492 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036129492 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20102310 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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