Healthcare Provider Details

I. General information

NPI: 1609180249
Provider Name (Legal Business Name): JOSE ANTONIO LUSANCAREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSE ANTONIO SANTIAGO PEREZ

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 02/22/2024
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRVING PARK RD
CHICAGO IL
60613-3077
US

IV. Provider business mailing address

148 S BOLINGBROOK DR
BOLINGBROOK IL
60440-2852
US

V. Phone/Fax

Practice location:
  • Phone: 773-525-6780
  • Fax:
Mailing address:
  • Phone: 630-914-5373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberACN485
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN485
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTEM-COV19-20639
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: