Healthcare Provider Details

I. General information

NPI: 1245034743
Provider Name (Legal Business Name): RICARDO JOSE INFANZON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/03/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N 2ND ST UNIT 203
ST CHARLES IL
60174-1850
US

IV. Provider business mailing address

1094 CALLE 5
SAN JUAN PR
00927-5120
US

V. Phone/Fax

Practice location:
  • Phone: 630-377-5105
  • Fax:
Mailing address:
  • Phone: 787-507-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150114587
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: