Provider Demographics
NPI:1760438477
Name:AMPUERO, FERNANDO A (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:A
Last Name:AMPUERO
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:PO BOX 6811
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-6811
Mailing Address - Country:US
Mailing Address - Phone:773-521-6001
Mailing Address - Fax:773-521-1154
Practice Address - Street 1:3517 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3910
Practice Address - Country:US
Practice Address - Phone:773-521-6001
Practice Address - Fax:773-521-1154
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036066158207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE22298Medicare UPIN