Healthcare Provider Details

I. General information

NPI: 1730682576
Provider Name (Legal Business Name): MIGUEL BARAJAS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST RM 1225
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

100 COMMERCE LN APT 1404
BETHESDA MD
20814-6269
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-0732
  • Fax:
Mailing address:
  • Phone: 630-518-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number036-165600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: