Provider Demographics
NPI:1659030195
Name:DELA PENA, EDISON V MENDOZA
Entity Type:Individual
Prefix:
First Name:EDISON V
Middle Name:MENDOZA
Last Name:DELA PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9429 BAY COLONY DR APT 1S
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-3623
Mailing Address - Country:US
Mailing Address - Phone:224-619-0724
Mailing Address - Fax:
Practice Address - Street 1:9429 BAY COLONY DR
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-3623
Practice Address - Country:US
Practice Address - Phone:224-619-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD41521302250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine