Healthcare Provider Details

I. General information

NPI: 1740785005
Provider Name (Legal Business Name): MAYELA BEATRIZ LEAL CHANCHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ERIE CT STE 6160
OAK PARK IL
60302-2519
US

IV. Provider business mailing address

3 ERIE CT STE 6160
OAK PARK IL
60302-2519
US

V. Phone/Fax

Practice location:
  • Phone: 708-434-4007
  • Fax: 708-434-4008
Mailing address:
  • Phone: 708-434-4007
  • Fax: 708-434-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number287319
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number036167084
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: