Provider Demographics
NPI:1609180249
Name:LUSANCAREZ, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:LUSANCAREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:ANTONIO
Other - Last Name:SANTIAGO PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:148 S BOLINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2852
Mailing Address - Country:US
Mailing Address - Phone:630-914-5373
Mailing Address - Fax:
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-525-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN485207QA0401X, 208D00000X
ILTEM-COV19-20639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice