Provider Demographics
NPI:1083653927
Name:CONSALTER, MAURICIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:A
Last Name:CONSALTER
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 1:355 W DUNDEE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3500
Mailing Address - Country:US
Mailing Address - Phone:847-541-4878
Mailing Address - Fax:847-520-0500
Practice Address - Street 1:2381 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2924
Practice Address - Country:US
Practice Address - Phone:773-227-2687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36100573207R00000X
IL036100573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100573Medicaid
ILH15929Medicare UPIN
IL036100573Medicaid