Healthcare Provider Details

I. General information

NPI: 1942457221
Provider Name (Legal Business Name): JOSE A AYALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 09/18/2023
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5406 W FULLERTON AVENUE
CHICAGO IL
60639-1427
US

IV. Provider business mailing address

2839 W WELLINGTON AVE # 2512
CHICAGO IL
60618-7037
US

V. Phone/Fax

Practice location:
  • Phone: 773-466-7012
  • Fax:
Mailing address:
  • Phone: 786-301-4903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036119906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: