Provider Demographics
NPI:1558967828
Name:GATILLO, JAN ANDY DONGON
Entity Type:Individual
Prefix:
First Name:JAN ANDY
Middle Name:DONGON
Last Name:GATILLO
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 1:8739 N ELMORE ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1943
Mailing Address - Country:US
Mailing Address - Phone:224-266-7819
Mailing Address - Fax:
Practice Address - Street 1:5946 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5424
Practice Address - Country:US
Practice Address - Phone:773-775-6637
Practice Address - Fax:773-775-6638
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist