MEDICARE: MS. ANGELA ILESILA DOUGE RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1457593600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELA ILESILA DOUGE RD

Provider Business Mailing Address
First Line	:	169 N GROVE AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60301-1329
Country	:	US
Telephone Number	:	708-426-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	439 E 31ST ST
Second Line	:	SUITE 215
City	:	CHICAGO
State	:	IL
Zip	:	60616-4000
Country	:	US
Telephone Number	:	312-949-1010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2009
Last Update Date	:	04/02/2009

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