Provider Demographics
NPI:1407818545
Name:DACUYCUY, WILFREDO GARDUQUE (MD)
Entity Type:Individual
Prefix:MR
First Name:WILFREDO
Middle Name:GARDUQUE
Last Name:DACUYCUY
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 1:5030 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3455
Mailing Address - Country:US
Mailing Address - Phone:847-785-0611
Mailing Address - Fax:
Practice Address - Street 1:1809 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-2235
Practice Address - Country:US
Practice Address - Phone:847-785-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3654557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054557Medicaid
IL036054557Medicaid
IL490770Medicare PIN