Healthcare Provider Details

I. General information

NPI: 1326071887
Provider Name (Legal Business Name): JULIO R LORET DE MOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST SUITE 0100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

751 N RUTLEDGE ST STE 3100
SPRINGFIELD IL
62702-4968
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-3119
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-118863
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number036-118863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: