Provider Demographics
NPI:1558112672
Name:MELENDRES-GOMES, EDILSAR AMILCAR
Entity Type:Individual
Prefix:
First Name:EDILSAR
Middle Name:AMILCAR
Last Name:MELENDRES-GOMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 W CORTEZ ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-3933
Mailing Address - Country:US
Mailing Address - Phone:925-596-0573
Mailing Address - Fax:
Practice Address - Street 1:1445 W CORTEZ ST APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-3933
Practice Address - Country:US
Practice Address - Phone:925-596-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer