Healthcare Provider Details

I. General information

NPI: 1760438477
Provider Name (Legal Business Name): FERNANDO A AMPUERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3517 W 26TH ST
CHICAGO IL
60623-3910
US

IV. Provider business mailing address

PO BOX 6811
CHICAGO IL
60680-6811
US

V. Phone/Fax

Practice location:
  • Phone: 773-521-6001
  • Fax: 773-521-1154
Mailing address:
  • Phone: 773-521-6001
  • Fax: 773-521-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036066158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: