Healthcare Provider Details

I. General information

NPI: 1326120999
Provider Name (Legal Business Name): AGUSTIN DEQUINA DORMITORIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 N PAULINA ST
CHICAGO IL
60640-2772
US

IV. Provider business mailing address

1109 HYDE PARK LN
NAPERVILLE IL
60565-1622
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9040
  • Fax:
Mailing address:
  • Phone: 773-578-1464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: