Healthcare Provider Details

I. General information

NPI: 1851597066
Provider Name (Legal Business Name): JUANITA RODRIGUEZ AGUILA-CORRALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUANITA AGUILA CORRALES MD

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ILLINI DRIVE
PEORIA IL
61605-2576
US

IV. Provider business mailing address

530 N.E. GLEN OAK
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-671-8504
  • Fax: 309-671-8513
Mailing address:
  • Phone: 773-484-1000
  • Fax: 309-655-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036114194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: