Healthcare Provider Details

I. General information

NPI: 1407084759
Provider Name (Legal Business Name): ROBERTO GORDILLO PEREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROBERTO GORDILLO

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE DEPARTMENT OF PEDIATRICS
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE DEPARTMENT OF PEDIATRICS
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-3313
  • Fax: 309-655-2565
Mailing address:
  • Phone: 309-624-3313
  • Fax: 309-655-2565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.126924
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036.126924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: