Healthcare Provider Details

I. General information

NPI: 1659116705
Provider Name (Legal Business Name): DMITRIY IGOREVICH GUBAREV NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2024
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 HARRISON ST
YORKVILLE IL
60560-6027
US

IV. Provider business mailing address

4555 HARRISON ST
YORKVILLE IL
60560-6027
US

V. Phone/Fax

Practice location:
  • Phone: 630-649-2781
  • Fax:
Mailing address:
  • Phone: 630-649-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041500862
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: