Provider Demographics
NPI:1821066879
Name:MANTECA-ELIAS, JESUS ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:ANTONIO
Last Name:MANTECA-ELIAS
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 1:1832 WEEG WAY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1230
Mailing Address - Country:US
Mailing Address - Phone:847-384-0346
Mailing Address - Fax:847-384-0543
Practice Address - Street 1:494 LEE ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4607
Practice Address - Country:US
Practice Address - Phone:847-297-1515
Practice Address - Fax:847-297-3390
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26132207Q00000X
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03609197802Medicaid
ILG52960Medicare UPIN
IL207140Medicare ID - Type Unspecified