Healthcare Provider Details

I. General information

NPI: 1760782544
Provider Name (Legal Business Name): EMERITO F. URETA, M.D.LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 NORTH CALDWELL STREET SUITE 20
STAUNTON IL
62088-1423
US

IV. Provider business mailing address

428 NORTH CALDWELL STREET SUITE 20
STAUNTON IL
62088-1423
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-5511
  • Fax: 618-635-5514
Mailing address:
  • Phone: 618-635-5511
  • Fax: 618-635-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036045117
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036045117
License Number StateIL

VIII. Authorized Official

Name: EMERITO F URETA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-635-5511