Provider Demographics
NPI:1326071887
Name:LORET DE MOLA, JULIO R (MD)
Entity Type:Individual
Prefix:
First Name:JULIO
Middle Name:R
Last Name:LORET DE MOLA
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 1:751 N RUTLEDGE ST
Mailing Address - Street 2:STE 3100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4968
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 0100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-3119
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-118863207V00000X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118863Medicaid
IL036118863Medicaid
F79801Medicare UPIN
IL036118863Medicaid