Healthcare Provider Details

I. General information

NPI: 1073541660
Provider Name (Legal Business Name): LEONEL ANTONIO URDANETA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E ONTARIO ST 12TH FLOOR
CHICAGO IL
60611-3468
US

IV. Provider business mailing address

211 E ONTARIO ST 12TH FLOOR
CHICAGO IL
60611-3468
US

V. Phone/Fax

Practice location:
  • Phone: 312-469-4905
  • Fax: 312-469-4905
Mailing address:
  • Phone: 312-469-4905
  • Fax: 312-469-4905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036119700
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: