Healthcare Provider Details

I. General information

NPI: 1841382959
Provider Name (Legal Business Name): FIDEL ECHEVARRIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax: 773-765-0801
Mailing address:
  • Phone: 773-769-0205
  • Fax: 773-765-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036100897
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: