Provider Demographics
NPI:1154449908
Name:OGURKIEWICZ, GARY ROMAN (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROMAN
Last Name:OGURKIEWICZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43090
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643
Mailing Address - Country:US
Mailing Address - Phone:773-779-6111
Mailing Address - Fax:773-779-6666
Practice Address - Street 1:10021 SOUTH WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:773-779-6111
Practice Address - Fax:773-779-6666
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632908OtherBLUE SHIELD
IL01632908OtherBLUE SHIELD