Healthcare Provider Details

I. General information

NPI: 1114126000
Provider Name (Legal Business Name): EDWIN V. GUMAPAS M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N VIRGINIA ST SUITE 2B
CRYSTAL LAKE IL
60014-4106
US

IV. Provider business mailing address

44 N VIRGINIA ST SUITE 2B
CRYSTAL LAKE IL
60014-4106
US

V. Phone/Fax

Practice location:
  • Phone: 815-356-0475
  • Fax: 815-356-0796
Mailing address:
  • Phone: 815-356-0475
  • Fax: 815-356-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036084823
License Number StateIL

VIII. Authorized Official

Name: MRS. DAWN THOMAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-356-0475