Provider Demographics
NPI:1699192690
Name:CARVALHO, PRISCILLA MEDEIROS (MD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MEDEIROS
Last Name:CARVALHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:CUSTODIO VILARINHO
Other - Last Name:MEDEIROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:430 PENNSYLVANIA AVE STE 210
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4464
Practice Address - Country:US
Practice Address - Phone:630-469-7700
Practice Address - Fax:630-545-7851
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142791208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program