Healthcare Provider Details

I. General information

NPI: 1184187767
Provider Name (Legal Business Name): MARITZA YESENIA ESTRADA-O'BRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 E 12TH ST STE 600
MENDOTA IL
61342-9012
US

IV. Provider business mailing address

1405 E 12TH ST STE 600
MENDOTA IL
61342-9012
US

V. Phone/Fax

Practice location:
  • Phone: 815-538-7200
  • Fax:
Mailing address:
  • Phone: 815-538-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.158388
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: