Healthcare Provider Details

I. General information

NPI: 1942381496
Provider Name (Legal Business Name): LUIS J CACERES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 E LAKE SHORE DR STE 105
DECATUR IL
62521-3800
US

IV. Provider business mailing address

1770 E LAKE SHORE DR STE 105
DECATUR IL
62521-3800
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-6100
  • Fax: 833-784-5326
Mailing address:
  • Phone: 217-422-6100
  • Fax: 833-784-5326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number036-084129
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-084129
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: