Healthcare Provider Details

I. General information

NPI: 1699864124
Provider Name (Legal Business Name): IMELDA S CARLOS MD FAAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 THORNHILL DR SUITE F
CAROL STREAM IL
60188
US

IV. Provider business mailing address

511 THORNHILL DR SUITE F
CAROL STREAM IL
60188
US

V. Phone/Fax

Practice location:
  • Phone: 630-462-7330
  • Fax: 630-462-7385
Mailing address:
  • Phone: 630-462-7330
  • Fax: 630-462-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036061984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: