Provider Demographics
NPI:1033101092
Name:GUMAPAS, EDWIN VERA (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:VERA
Last Name:GUMAPAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 S VIRGINIA ST
Mailing Address - Street 2:STE 201
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5800
Mailing Address - Country:US
Mailing Address - Phone:815-356-0475
Mailing Address - Fax:815-356-0796
Practice Address - Street 1:25 S VIRGINIA ST
Practice Address - Street 2:STE 201
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5800
Practice Address - Country:US
Practice Address - Phone:815-356-0475
Practice Address - Fax:815-356-0796
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F54320Medicare UPIN
ILK01482Medicare PIN