Provider Demographics
NPI:1073541660
Name:URDANETA, LEONEL ANTONIO JR (MD)
Entity Type:Individual
Prefix:
First Name:LEONEL
Middle Name:ANTONIO
Last Name:URDANETA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E ONTARIO ST
Mailing Address - Street 2:12TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3468
Mailing Address - Country:US
Mailing Address - Phone:312-469-4905
Mailing Address - Fax:312-469-4905
Practice Address - Street 1:211 E ONTARIO ST
Practice Address - Street 2:12TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3468
Practice Address - Country:US
Practice Address - Phone:312-469-4905
Practice Address - Fax:312-469-4905
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILVAD000Medicaid
ILVAD000Medicaid