1619453412 NPI number — ANGEL CRISTIAN DE LA CRUZ TEJADA MD

Table of content: ANGEL CRISTIAN DE LA CRUZ TEJADA MD (NPI 1619453412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619453412 NPI number — ANGEL CRISTIAN DE LA CRUZ TEJADA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA CRUZ TEJADA
Provider First Name:
ANGEL
Provider Middle Name:
CRISTIAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1619453412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 HARVESTER DR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-6686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-702-1150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5841 S. MARYLAND AVENUE MC 1052
Provider Second Line Business Practice Location Address:
DPT. OF GME ROOM J-141
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60637-1470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-702-1842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2018

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: 207RC0000X , with the licence number:  036.168196 , 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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