Provider Demographics
NPI:1760555775
Name:DADIVAS, JESUS RENE (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:RENE
Last Name:DADIVAS
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 1:8430 W PETER TER
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1852
Mailing Address - Country:US
Mailing Address - Phone:847-825-3906
Mailing Address - Fax:773-772-8770
Practice Address - Street 1:3426 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3720
Practice Address - Country:US
Practice Address - Phone:773-772-8770
Practice Address - Fax:773-772-8770
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-53403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL497960Medicare ID - Type UnspecifiedMEDICARE
ILC42556Medicare UPIN