Healthcare Provider Details

I. General information

NPI: 1235484866
Provider Name (Legal Business Name): CARLOS ERNESTO NOLASCO MORALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 S BATES AVE
SPRINGFIELD IL
62704-4337
US

IV. Provider business mailing address

2317 S BATES AVE
SPRINGFIELD IL
62704-4337
US

V. Phone/Fax

Practice location:
  • Phone: 866-477-7472
  • Fax: 217-717-2268
Mailing address:
  • Phone: 866-477-7472
  • Fax: 217-717-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-138431
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License Number036138431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: