Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086X0206X | Surgical Oncologist | 036.062224 | IL |
NPI | 1356328728 |
---|---|
Provider Name | Dr. Alfonso V Mellijor |
First Address | Zion, IL 60099 |
Second Address | Chicago, IL 60674 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2005 |
Last Update Date | 06/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B55011 | (02) | IL |
L73618 | (02) |