Healthcare Provider Details

I. General information

NPI: 1245580653
Provider Name (Legal Business Name): MA. OLIVIA R. SAN DIEGO, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MOZART ST SUITE 205
CHICAGO IL
60622-2789
US

IV. Provider business mailing address

1044 N MOZART ST SUITE 205
CHICAGO IL
60622-2789
US

V. Phone/Fax

Practice location:
  • Phone: 773-489-2913
  • Fax: 773-489-7330
Mailing address:
  • Phone: 773-489-2913
  • Fax: 773-489-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-130487
License Number StateIL

VIII. Authorized Official

Name: DR. MA. OLIVIA ROQUE SAN DIEGO
Title or Position: DIRECTOR
Credential: M.D.
Phone: 973-653-6119