Provider Demographics
NPI:1497898589
Name:ANGARITA, LUIS JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:JOSE
Last Name:ANGARITA
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 1:4007 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4605
Mailing Address - Country:US
Mailing Address - Phone:773-767-2266
Mailing Address - Fax:773-767-4380
Practice Address - Street 1:4007 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4605
Practice Address - Country:US
Practice Address - Phone:773-767-2266
Practice Address - Fax:773-767-4380
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060246Medicaid
IL036060246Medicaid