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General NPI Number Information
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NPI Number | 1407818545
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Entity Type | Individual
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Provider Name | WILFREDO GARDUQUE DACUYCUY M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/04/2006
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Last Update Date | 11/21/2016
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Provider Practice Location Address
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Address Line | 1809 SHERIDAN RD
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City | NORTH CHICAGO
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State | IL
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Zip | 60064-2235
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Country | US
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Telephone | 847-785-0611
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Fax |
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Provider Business Mailing Address
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Address Line | 5030 CHASE AVE
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City | SKOKIE
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State | IL
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Zip | 60077-3455
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Country | US
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Telephone | 847-785-0611
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 3654557
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License Number State | IL
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