Healthcare Provider Details

I. General information

NPI: 1861864332
Provider Name (Legal Business Name): CHARLES V LOZADA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W 22ND ST SUITE 610
OAK BROOK IL
60523-2006
US

IV. Provider business mailing address

1034 MIDWAY RD
NORTHBROOK IL
60062-3936
US

V. Phone/Fax

Practice location:
  • Phone: 630-537-1720
  • Fax: 773-326-3518
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209013467
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: