Provider Demographics
NPI:1205834934
Name:LIBOON, ROGELIO N (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGELIO
Middle Name:N
Last Name:LIBOON
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 1:1937 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1206
Mailing Address - Country:US
Mailing Address - Phone:773-523-8014
Mailing Address - Fax:630-654-4362
Practice Address - Street 1:1937 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1206
Practice Address - Country:US
Practice Address - Phone:773-523-8014
Practice Address - Fax:630-654-4362
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047971Medicaid
K50915OtherMEDICARE PTAN
K50915OtherMEDICARE PTAN
IL036047971Medicaid