Healthcare Provider Details

I. General information

NPI: 1235128075
Provider Name (Legal Business Name): PABLO E CHAGOYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 CERMAK RD
BERWYN IL
60402-2313
US

IV. Provider business mailing address

6545 CERMAK RD
BERWYN IL
60402-2313
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-0077
  • Fax:
Mailing address:
  • Phone: 708-788-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036112461
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number036112461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: