Healthcare Provider Details

I. General information

NPI: 1063518488
Provider Name (Legal Business Name): YOLANDA LALYRE-RODRIGUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3538 W FULLERTON AVE MC 716
CHICAGO IL
60647-2443
US

IV. Provider business mailing address

3538 W FULLERTON AVE MC 716
CHICAGO IL
60647-2443
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-1212
  • Fax: 773-772-8666
Mailing address:
  • Phone: 773-772-1212
  • Fax: 773-772-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036051381
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: