Provider Demographics
NPI:1578596193
Name:NABONG, RICARDO N (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:N
Last Name:NABONG
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 1:4318 W CRYSTAL LAKE RD STE G
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4250
Mailing Address - Country:US
Mailing Address - Phone:815-344-0734
Mailing Address - Fax:815-344-0485
Practice Address - Street 1:4318 W CRYSTAL LAKE RD STE G
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4250
Practice Address - Country:US
Practice Address - Phone:815-344-0734
Practice Address - Fax:815-344-0485
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052875208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD09728Medicare UPIN
IL208300Medicare ID - Type Unspecified