Provider Demographics
NPI:1568457455
Name:OSORIO, LUIS ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:OSORIO
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 1:5201 WILLOW SPRINGS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6557
Mailing Address - Country:US
Mailing Address - Phone:708-245-8120
Mailing Address - Fax:
Practice Address - Street 1:7503 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1405
Practice Address - Country:US
Practice Address - Phone:708-484-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36087612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087612Medicaid
IL0001622949OtherBLUE CROSS BLUE SHIELD
IL0001622949OtherBLUE CROSS BLUE SHIELD
ILG37774Medicare UPIN