Provider Demographics
NPI:1346747292
Name:FONSECA-PARICIO, MARIO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:JOSE
Last Name:FONSECA-PARICIO
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 1:180 HARVESTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-4503
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S. MARYLAND AVE
Practice Address - Street 2:M/C 6076
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-9660
Practice Address - Fax:773-834-7068
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.156755207RP1001X, 207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1346747292Medicaid
IL036.156755OtherSTATE OF ILLINOIS