Provider Demographics
NPI:1891817565
Name:IBARRA, JUAN M (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:IBARRA
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 1:2830 MARVIN LN
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9315
Mailing Address - Country:US
Mailing Address - Phone:815-235-7093
Mailing Address - Fax:
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08932005OtherBCBS OF IL PROVIDER NBR
ILE90159Medicare UPIN
IL208991Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
IL08932005OtherBCBS OF IL PROVIDER NBR