Provider Demographics
NPI:1407089394
Name:HUERTA SUAREZ, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:HUERTA SUAREZ
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 1:201 WAVERLY PL
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-5908
Mailing Address - Country:US
Mailing Address - Phone:262-896-1029
Mailing Address - Fax:262-896-1029
Practice Address - Street 1:1431 N WESTERN AVE STE 503
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1776
Practice Address - Country:US
Practice Address - Phone:773-772-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128879Medicaid
IL036128879Medicaid