Provider Demographics
NPI:1609941319
Name:TREVINO, JOSE G SR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:G
Last Name:TREVINO
Suffix:SR
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 1:1200 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545
Mailing Address - Country:US
Mailing Address - Phone:630-552-7601
Mailing Address - Fax:630-552-9215
Practice Address - Street 1:1200 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545
Practice Address - Country:US
Practice Address - Phone:630-552-7601
Practice Address - Fax:630-552-9215
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36061677207Q00000X, 208600000X, 208600000X
IL1508873324363AM0700X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061677Medicaid
IL4722870OtherBCBS
IL4722870OtherBCBS