Healthcare Provider Details

I. General information

NPI: 1710728126
Provider Name (Legal Business Name): BRANDON ALEXANDER ESCOBEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2523 DEER POINT DR
MONTGOMERY IL
60538-4052
US

IV. Provider business mailing address

2523 DEER POINT DR
MONTGOMERY IL
60538-4052
US

V. Phone/Fax

Practice location:
  • Phone: 630-796-9084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberE213-0610-4043
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: