Provider Demographics
NPI:1073779179
Name:QUIJANO, CARLA V (MD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:V
Last Name:QUIJANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:PEDIATRIC RADIOLOGY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-3512
Mailing Address - Fax:312-227-9784
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:PEDIATRIC RADIOLOGY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-3512
Practice Address - Fax:312-227-9784
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-115570207U00000X
IL0361155702085N0904X, 2085R0202X, 2085P0229X
WI528032085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073779179Medicaid
WI680860668Medicare PIN
WI736011482Medicare PIN