Healthcare Provider Details

I. General information

NPI: 1376809509
Provider Name (Legal Business Name): JOMARIE ROSE OCAMPO RIVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 12/20/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 E 130TH ST
CHICAGO IL
60628-6908
US

IV. Provider business mailing address

1029 E 130TH ST
CHICAGO IL
60628-6908
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-6300
  • Fax:
Mailing address:
  • Phone: 773-995-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036137421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: