Provider Demographics
NPI:1396815601
Name:BANUELOS, GEORGE A (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:BANUELOS
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 1:3540 SEVEN BRIDGES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1222
Mailing Address - Country:US
Mailing Address - Phone:630-810-0777
Mailing Address - Fax:630-810-0395
Practice Address - Street 1:3540 SEVEN BRIDGES DR STE 200
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517
Practice Address - Country:US
Practice Address - Phone:630-810-0777
Practice Address - Fax:630-810-0395
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070501207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070501OtherSTATE LICENSE NUMBER
IL2201686OtherBCBS IL
IL036070501Medicaid
ILC44298Medicare UPIN
IL036070501Medicaid