Healthcare Provider Details

I. General information

NPI: 1720701071
Provider Name (Legal Business Name): JOHAN D SUGUITAN RD, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 N PAULINA ST
CHICAGO IL
60640-2772
US

IV. Provider business mailing address

8443 DRAKE AVE
SKOKIE IL
60076-2817
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9040
  • Fax:
Mailing address:
  • Phone: 773-396-9563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.004251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: