Healthcare Provider Details

I. General information

NPI: 1659364396
Provider Name (Legal Business Name): LAURO AMEZCUA-PATINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

4055 W CHANDLER BLVD SUITE #5
CHANDLER AZ
85226-3700
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone: 480-464-4431
  • Fax: 480-464-2338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberT6429
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD61530096
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17900
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4023
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC1-0026764
License Number StateDE
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036168702
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: