Healthcare Provider Details

I. General information

NPI: 1720174246
Provider Name (Legal Business Name): WILMAN ORTEGA PEREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR STE. 200
BELLEVILLE IL
62226-5368
US

IV. Provider business mailing address

4600 MEMORIAL DR STE. 200
BELLEVILLE IL
62226-5368
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-2220
  • Fax: 618-233-2555
Mailing address:
  • Phone: 618-233-2220
  • Fax: 618-233-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036098393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: