Provider Demographics
NPI:1437228806
Name:OROZA-HENNERS, GUSTAVO E (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:E
Last Name:OROZA-HENNERS
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 1:1205 N MARION ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1253
Mailing Address - Country:US
Mailing Address - Phone:312-666-5455
Mailing Address - Fax:
Practice Address - Street 1:1859 S BLUE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3012
Practice Address - Country:US
Practice Address - Phone:312-666-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083375208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083375Medicaid