Healthcare Provider Details

I. General information

NPI: 1689303273
Provider Name (Legal Business Name): CRYSTAL JUAREZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 215
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

1645 W JACKSON BLVD STE 215
CHICAGO IL
60612-3227
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-8028
  • Fax:
Mailing address:
  • Phone: 312-942-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.080502
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.080502
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: