Healthcare Provider Details

I. General information

NPI: 1487159604
Provider Name (Legal Business Name): BLANCA ANAIS ESTUPINAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E DEERPATH
LAKE FOREST IL
60045-1952
US

IV. Provider business mailing address

1607 S CRESCENT AVE
PARK RIDGE IL
60068-5309
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-6121
  • Fax:
Mailing address:
  • Phone: 863-409-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA1230740
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036177123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: