Provider Demographics
NPI:1740785005
Name:LEAL CHANCHI, MAYELA BEATRIZ (MD)
Entity Type:Individual
Prefix:
First Name:MAYELA
Middle Name:BEATRIZ
Last Name:LEAL CHANCHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ERIE CT STE 6160
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2519
Mailing Address - Country:US
Mailing Address - Phone:708-434-4007
Mailing Address - Fax:708-434-4008
Practice Address - Street 1:3 ERIE CT STE 6160
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:708-434-4007
Practice Address - Fax:708-434-4008
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2873192080S0010X
IL0361670842080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty