Provider Demographics
NPI:1629076781
Name:UGARTE, LUIS E (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:E
Last Name:UGARTE
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 1:152 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2619
Mailing Address - Country:US
Mailing Address - Phone:708-755-7359
Mailing Address - Fax:708-754-3071
Practice Address - Street 1:152 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2619
Practice Address - Country:US
Practice Address - Phone:708-755-7359
Practice Address - Fax:708-754-3071
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047127207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047127Medicaid
IL036047127Medicaid
367830Medicare PIN
ILC40255Medicare UPIN
ILL62079Medicare PIN