Provider Demographics
NPI:1407996564
Name:NUNEZ, AUSENCIO (MD)
Entity Type:Individual
Prefix:
First Name:AUSENCIO
Middle Name:
Last Name:NUNEZ
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 1:1841 W ARMY TRAIL RD
Mailing Address - Street 2:R
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1901
Mailing Address - Country:US
Mailing Address - Phone:630-238-9235
Mailing Address - Fax:630-238-0426
Practice Address - Street 1:1841 W ARMY TRAIL RD
Practice Address - Street 2:R
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1901
Practice Address - Country:US
Practice Address - Phone:630-238-9235
Practice Address - Fax:630-238-0426
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078267207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078267Medicaid
IL02205538OtherBCBS PROVIDER NUMBER
IL363950044OtherTAXID
ILCF9448OtherRAILROAD MEDICARE GROUP #
IL02205538OtherBCBS PROVIDER NUMBER
IL363950044OtherTAXID
IL373120Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL110153602Medicare ID - Type UnspecifiedRAILROAD MEDICARE