Provider Demographics
NPI:1285674564
Name:GOTARDO, CARLOS F (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:F
Last Name:GOTARDO
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 1:707 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-446-6410
Mailing Address - Fax:217-477-4757
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-446-6410
Practice Address - Fax:217-477-4757
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059520Medicaid
247880OtherUNITED HEALTHCARE
IN100014860AMedicaid
170579OtherPERSONAL CARE/COVENTRY
IN100014860AMedicaid
IL635921Medicare ID - Type UnspecifiedILLINOIS MEDICARE
IL036059520Medicaid