Healthcare Provider Details

I. General information

NPI: 1003610544
Provider Name (Legal Business Name): DIEGO ALEJANDRO PIVIDAL FERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 N OAKLEY BLVD FL 2
CHICAGO IL
60622-3507
US

IV. Provider business mailing address

1127 N OAKLEY BLVD FL 2
CHICAGO IL
60622-3507
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2040
  • Fax: 312-770-3270
Mailing address:
  • Phone: 312-770-2040
  • Fax: 312-770-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.086856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: