Healthcare Provider Details

I. General information

NPI: 1013747278
Provider Name (Legal Business Name): MAX JESUS BUSTILLO OROZCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

2850 N SHERIDAN RD APT 705
CHICAGO IL
60657-6140
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3000
  • Fax:
Mailing address:
  • Phone: 872-340-5819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.083893
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: