Provider Demographics
NPI:1003875741
Name:BRIEVA, JOAQUIN CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:CARLOS
Last Name:BRIEVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOAQUIN
Other - Middle Name:C
Other - Last Name:BRIEVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-8106
Mailing Address - Fax:312-695-0537
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 1600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-8106
Practice Address - Fax:312-695-0537
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085292207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58284Medicare UPIN