Healthcare Provider Details

I. General information

NPI: 1225447725
Provider Name (Legal Business Name): JEREMY R. ESTRADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC5841
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

96 CAMPUS DR
SCARBOROUGH ME
04074-7163
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.130657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: