Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 036.126924 | IL |
Y | 2080P0210X | Pediatric Nephrologist | 036.126924 | IL |
NPI | 1407084759 |
---|---|
Provider Name | Roberto Gordillo Perez |
First Address | Peoria, IL 61637-0001 |
Second Address | Peoria, IL 61637-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2009 |
Last Update Date | 12/04/2011 |