Provider Demographics
NPI:1437678133
Name:M D AESTHETICS AND DERMATOLOGY LLC
Entity Type:Organization
Organization Name:M D AESTHETICS AND DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTINEZ-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-579-0700
Mailing Address - Street 1:1021 W. ADAMS ST.
Mailing Address - Street 2:LL #1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-579-0700
Mailing Address - Fax:312-579-0701
Practice Address - Street 1:1021 W ADAMS ST
Practice Address - Street 2:LL # 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2934
Practice Address - Country:US
Practice Address - Phone:312-579-0700
Practice Address - Fax:312-579-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138747207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty