Provider Demographics
NPI:1407468598
Name:TEJADA, DULCE M
Entity Type:Individual
Prefix:
First Name:DULCE
Middle Name:M
Last Name:TEJADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N CLAREMONT AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1702
Mailing Address - Country:US
Mailing Address - Phone:312-633-5890
Mailing Address - Fax:
Practice Address - Street 1:1431 N CLAREMONT AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1702
Practice Address - Country:US
Practice Address - Phone:312-633-5890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty