Provider Demographics
NPI:1851745269
Name:ROSAS-VIDAL, LUIS EDUARDO (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:EDUARDO
Last Name:ROSAS-VIDAL
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2954
Mailing Address - Country:US
Mailing Address - Phone:312-695-5060
Mailing Address - Fax:312-695-5010
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2954
Practice Address - Country:US
Practice Address - Phone:312-695-5060
Practice Address - Fax:312-695-5010
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN614782084P0800X
390200000X
IL0361615902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program