Healthcare Provider Details

I. General information

NPI: 1922119957
Provider Name (Legal Business Name): AILEEN GOMEZ-TORRES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 26TH ST
CHICAGO IL
60623-3824
US

IV. Provider business mailing address

3700 W 26TH ST
CHICAGO IL
60623-3824
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-5203
  • Fax: 773-542-5841
Mailing address:
  • Phone: 773-542-5203
  • Fax: 773-542-5841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-103472
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: