Healthcare Provider Details

I. General information

NPI: 1891817565
Provider Name (Legal Business Name): JUAN M IBARRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W STEPHENSON ST
FREEPORT IL
61032-4864
US

IV. Provider business mailing address

2830 MARVIN LN
FREEPORT IL
61032-9315
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6159
  • Fax:
Mailing address:
  • Phone: 815-235-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036082621
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036082621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: