Provider Demographics
NPI:1184686149
Name:MUTUA, JERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:MUTUA
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 1:6810 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1510
Mailing Address - Country:US
Mailing Address - Phone:773-994-5502
Mailing Address - Fax:773-994-7405
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:ST. BERNARDS HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-994-5502
Practice Address - Fax:773-994-7405
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207Q0000XOtherTAXONOMY
IL036062092Medicaid
ILD14669Medicare UPIN
IL207Q0000XOtherTAXONOMY
ILK12665Medicare PIN