Healthcare Provider Details

I. General information

NPI: 1235517228
Provider Name (Legal Business Name): CARLA CHONILLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST # 256
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

3880 SALEM LAKE DR STE F
LONG GROVE IL
60047-5292
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3364
  • Fax:
Mailing address:
  • Phone: 847-719-2220
  • Fax: 847-719-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036147457
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036147457
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA11460100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: