Provider Demographics
NPI:1346556057
Name:HENRY LOPEZ CORDERO, M.D., S.C.
Entity Type:Organization
Organization Name:HENRY LOPEZ CORDERO, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-277-1740
Mailing Address - Street 1:2 WELLINGBOROUGH CT
Mailing Address - Street 2:
Mailing Address - City:S BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-6156
Mailing Address - Country:US
Mailing Address - Phone:847-277-1740
Mailing Address - Fax:847-277-1744
Practice Address - Street 1:2002 N DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4527
Practice Address - Country:US
Practice Address - Phone:773-486-6553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048675174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048675Medicaid
IL00216062921OtherBCBS
IL14D0873925EFFEOtherCLIA
ILC41854Medicare UPIN
IL036048675Medicaid