1619350410 NPI number — CRISTINA ISABEL ANEZ DE GOMEZ MD

Table of content: CRISTINA ISABEL ANEZ DE GOMEZ MD (NPI 1619350410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619350410 NPI number — CRISTINA ISABEL ANEZ DE GOMEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANEZ DE GOMEZ
Provider First Name:
CRISTINA
Provider Middle Name:
ISABEL
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:
1619350410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 GREEN BAY ROAD 1083 RWCLC
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT LAKES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60064-3037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-722-6221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 N WESTMORELAND RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045-1687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-535-7157
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2015

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: 207R00000X , with the licence number:  125067298 , 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)





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