Healthcare Provider Details

I. General information

NPI: 1669789020
Provider Name (Legal Business Name): JAVIER ALFONSO GOMEZ VALENCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1900 W POLK ST
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 312-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036130372
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number036-130372
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-130372
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: