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General NPI Number Information
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NPI Number | 1437678133
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Entity Type | Organization
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Legal Business Name | M D AESTHETICS AND DERMATOLOGY LLC
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Dates
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Enumeration Date | 09/13/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1021 W ADAMS ST LL # 1
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City | CHICAGO
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State | IL
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Zip | 60607-2934
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Country | US
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Telephone | 312-579-0700
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Fax | 312-579-0701
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Provider Business Mailing Address
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Address Line | 1021 W. ADAMS ST. LL #1
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City | CHICAGO
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State | IL
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Zip | 60607
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Country | US
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Telephone | 312-579-0700
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Fax | 312-579-0701
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/DERMATOLOGIST
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Name | DR. GABRIEL J. MARTINEZ-DIAZ
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Credential | M.D.
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Telephone | 312-579-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 036138747
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 036138747
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 036138747
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License Number State | IL
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