Healthcare Provider Details

I. General information

NPI: 1982665196
Provider Name (Legal Business Name): LEO M FARBOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 FLETCHER DR SUITE 302
ELGIN IL
60123-4747
US

IV. Provider business mailing address

PO BOX 1509
ELGIN IL
60121-1509
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-6600
  • Fax: 847-695-4279
Mailing address:
  • Phone: 224-238-4160
  • Fax: 847-783-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036070813
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036070813
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: