Provider Demographics
NPI:1497715908
Name:PLASENCIA, WALTER RUBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RUBEN
Last Name:PLASENCIA
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 1:5939 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1155
Mailing Address - Country:US
Mailing Address - Phone:773-637-1600
Mailing Address - Fax:773-637-2733
Practice Address - Street 1:5939 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1155
Practice Address - Country:US
Practice Address - Phone:773-637-1600
Practice Address - Fax:773-637-2733
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092042Medicaid
ILG36108Medicare UPIN
ILL55097Medicare UPIN