Healthcare Provider Details

I. General information

NPI: 1457766727
Provider Name (Legal Business Name): FERNANDO AGUIRRE AMEZQUITA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST
SPRINGFIELD IL
62702-5303
US

IV. Provider business mailing address

PO BOX 19640
SPRINGFIELD IL
62794-9640
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-5117
  • Fax: 217-545-9217
Mailing address:
  • Phone: 217-545-5117
  • Fax: 217-545-9217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125065574
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: