Healthcare Provider Details

I. General information

NPI: 1437228806
Provider Name (Legal Business Name): GUSTAVO E OROZA-HENNERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 S BLUE ISLAND AVE
CHICAGO IL
60608-3012
US

IV. Provider business mailing address

1205 N MARION ST
OAK PARK IL
60302-1253
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-5455
  • Fax:
Mailing address:
  • Phone: 312-666-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-083375
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: