Provider Demographics
NPI:1679630156
Name:ILADA, PATRICIO LUIS IV (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIO
Middle Name:LUIS
Last Name:ILADA
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5114 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4686
Mailing Address - Country:US
Mailing Address - Phone:309-683-6600
Mailing Address - Fax:309-683-2412
Practice Address - Street 1:5114 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4686
Practice Address - Country:US
Practice Address - Phone:309-683-6600
Practice Address - Fax:309-683-2412
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI35992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32089400Medicaid
WIF53341Medicare UPIN
WI000032430Medicare ID - Type UnspecifiedMEDICARE NUMBER