Healthcare Provider Details

I. General information

NPI: 1245486679
Provider Name (Legal Business Name): MA CLARAVEL BARICUATRO CRISTE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2102 WINDSOR DR
MARION IL
62959-1472
US

IV. Provider business mailing address

2102 WINDSOR DR
MARION IL
62959-1472
US

V. Phone/Fax

Practice location:
  • Phone: 618-364-0348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1255051150
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.121657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: