Provider Demographics
NPI:1578562351
Name:IGLESIAS, MANUEL C (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:C
Last Name:IGLESIAS
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 1:1350 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4042
Mailing Address - Country:US
Mailing Address - Phone:708-681-0070
Mailing Address - Fax:
Practice Address - Street 1:1225 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4039
Practice Address - Country:US
Practice Address - Phone:708-681-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2020-01-15
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL036047918207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047918Medicaid
IL21607825OtherBLUE SHIELD OF ILLINOIS
ILD13282Medicare UPIN