Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 125075440 | IL |
Y | 111NI0900X | Internist | 125075440 | IL |
NPI | 1003426743 |
---|---|
Provider Name | Carlos Andres Rueda Mantilla |
First Address | Chicago, IL 60613-1747 |
Second Address | Chicago, IL 60640-5759 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2020 |
Last Update Date | 07/08/2020 |