Provider Demographics
NPI:1245580653
Name:MA. OLIVIA R. SAN DIEGO, M.D., S.C.
Entity Type:Organization
Organization Name:MA. OLIVIA R. SAN DIEGO, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MA. OLIVIA
Authorized Official - Middle Name:ROQUE
Authorized Official - Last Name:SAN DIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-653-6119
Mailing Address - Street 1:1044 N MOZART ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2789
Mailing Address - Country:US
Mailing Address - Phone:773-489-2913
Mailing Address - Fax:773-489-7330
Practice Address - Street 1:1044 N MOZART ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2789
Practice Address - Country:US
Practice Address - Phone:773-489-2913
Practice Address - Fax:773-489-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-130487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty