Healthcare Provider Details

I. General information

NPI: 1801077094
Provider Name (Legal Business Name): VICTOR RAFAEL PLASENCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5939 W DIVERSEY AVE
CHICAGO IL
60639-1155
US

IV. Provider business mailing address

5939 W DIVERSEY AVE
CHICAGO IL
60639-1155
US

V. Phone/Fax

Practice location:
  • Phone: 773-637-1600
  • Fax: 773-637-2733
Mailing address:
  • Phone: 773-637-1600
  • Fax: 773-637-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number03112680
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: