Provider Demographics
NPI:1467437939
Name:PAREJA, AUGUSTO N (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:N
Last Name:PAREJA
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 1:3232 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2638
Mailing Address - Country:US
Mailing Address - Phone:773-434-8026
Mailing Address - Fax:773-434-8107
Practice Address - Street 1:3232 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2638
Practice Address - Country:US
Practice Address - Phone:773-434-8026
Practice Address - Fax:773-434-8107
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2012-06-08
Deactivation Date:2006-02-01
Deactivation Code:
Reactivation Date:2006-08-30
Provider Licenses
StateLicense IDTaxonomies
IL036065907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065907 / 03Medicaid
IL01621679OtherBCBS OF IL
ILD15037Medicare UPIN
ILK24893Medicare PIN