Healthcare Provider Details

I. General information

NPI: 1992559678
Provider Name (Legal Business Name): JUAN DAVID IDARRAGA PARRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 SOUTH WOOD STREET UI HEALTH, GRADUATE MEDICAL EDUCA SUITE 100, MC 675
CHICAGO IL
60612
US

IV. Provider business mailing address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2933
  • Fax:
Mailing address:
  • Phone: 312-996-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125084845
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: