Provider Demographics
NPI:1659454619
Name:GUEVARA, JOSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:GUEVARA
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 1:1486 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5917
Mailing Address - Country:US
Mailing Address - Phone:847-658-6667
Mailing Address - Fax:847-658-6669
Practice Address - Street 1:1486 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5917
Practice Address - Country:US
Practice Address - Phone:847-658-6667
Practice Address - Fax:847-658-6669
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005600189OtherBLUE CROSS BLUE SHIELD
IL0005600189OtherBLUE CROSS BLUE SHIELD
ILK22761Medicare PIN