Healthcare Provider Details

I. General information

NPI: 1952690422
Provider Name (Legal Business Name): JESUS RENE DADIVAS II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 S DEARBORN ST
CHICAGO IL
60605-1838
US

IV. Provider business mailing address

8430 W PETER TER
NILES IL
60714-1852
US

V. Phone/Fax

Practice location:
  • Phone: 312-588-1104
  • Fax:
Mailing address:
  • Phone: 847-825-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036130079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: