Healthcare Provider Details

I. General information

NPI: 1144778325
Provider Name (Legal Business Name): COSME R. CAGAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: COSMELITO RALOTA CAGAS JR. MD

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BUHKUM WOODS DR.
FAIRVIEW HTS. IL
62208-0000
US

IV. Provider business mailing address

1 BUHKUM WOODS DR.
FAIRVIEW HTS. IL
62208-0000
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-6308
  • Fax:
Mailing address:
  • Phone: 618-398-6308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36052410
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: