Provider Demographics
NPI:1639307283
Name:MENA LORA, ALFREDO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:JOSE
Last Name:MENA LORA
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 1:2875 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3501
Mailing Address - Country:US
Mailing Address - Phone:773-484-1000
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:773-484-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129081208600000X
IL125056547390200000X
IL036129801207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program