Provider Demographics
NPI:1073557740
Name:MAYUGA, RUPERTO (MD)
Entity Type:Individual
Prefix:
First Name:RUPERTO
Middle Name:
Last Name:MAYUGA
Suffix:
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 1:18W 163 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561
Mailing Address - Country:US
Mailing Address - Phone:773-281-7660
Mailing Address - Fax:773-281-0841
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-281-7660
Practice Address - Fax:773-281-0841
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075687207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605124OtherBLUE CROSS BLUE SHIELD IL
IL036075687Medicaid
IL036075687Medicaid