Provider Demographics
NPI:1104849595
Name:BUENVENIDA, CARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:
Last Name:BUENVENIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 555
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-698-5500
Mailing Address - Fax:847-698-0226
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 555
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-698-5500
Practice Address - Fax:847-698-0226
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092596207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092596Medicaid
ILL99084Medicare UPIN
ILG62227Medicare UPIN