Provider Demographics
NPI:1003426743
Name:RUEDA MANTILLA, CARLOS ANDRES (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANDRES
Last Name:RUEDA MANTILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:ANDRES
Other - Last Name:RUEDA MANTILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4250 N MARINE DR APT 2333
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1747
Mailing Address - Country:US
Mailing Address - Phone:312-826-1105
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:312-826-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125075440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine