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General NPI Number Information
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NPI Number | 1780957654
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Entity Type | Organization
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Legal Business Name | DR. MARY DEHERRERA-CODO MD PC
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Dates
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Enumeration Date | 02/22/2012
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Last Update Date | 02/22/2012
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Provider Practice Location Address
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Address Line | 720 BROM CT SUIT 204
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City | NAPERVILLE
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State | IL
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Zip | 60540-6531
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Country | US
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Telephone | 630-848-1332
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Fax | 630-838-1344
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Provider Business Mailing Address
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Address Line | 720 BROM CT SUIT 204
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City | NAPERVILLE
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State | IL
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Zip | 60540-6531
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Country | US
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Telephone | 630-848-1332
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Fax | 630-838-1344
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY DEHERRERA-CODO
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Credential | MD
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Telephone | 630-848-1332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 03-6082140
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License Number State | IL
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