Healthcare Provider Details

I. General information

NPI: 1699888644
Provider Name (Legal Business Name): JOSE LUIS RIOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 ESSINGTON RD
JOLIET IL
60435-8423
US

IV. Provider business mailing address

820 SPRINGER DR
LOMBARD IL
60148-6413
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-8554
  • Fax: 815-744-3969
Mailing address:
  • Phone: 708-634-4602
  • Fax: 630-495-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2020-00458
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036-109103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: