Healthcare Provider Details

I. General information

NPI: 1851775860
Provider Name (Legal Business Name): IVAN JOSE CUESTA ISABEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 12/14/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST STE AIP
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-6790
  • Fax: 847-723-6799
Mailing address:
  • Phone: 215-707-5734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMT209694
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036156358
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: