Provider Demographics
NPI:1578668059
Name:MEZA, EDUARDO D (MD)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:D
Last Name:MEZA
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 1:6030 GARRETT LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6637
Mailing Address - Country:US
Mailing Address - Phone:815-226-1172
Mailing Address - Fax:815-226-1595
Practice Address - Street 1:6030 GARRETT LN
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6637
Practice Address - Country:US
Practice Address - Phone:815-226-1172
Practice Address - Fax:815-226-1595
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL548350Medicare PIN
ILD14168Medicare UPIN