Provider Demographics
NPI:1902369689
Name:LOCQUIAO, JEREMIAH JOHN COMBS (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH JOHN
Middle Name:COMBS
Last Name:LOCQUIAO
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 1:1020 SANSOM ST STE 1651B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5002
Mailing Address - Country:US
Mailing Address - Phone:215-955-9837
Mailing Address - Fax:215-955-9870
Practice Address - Street 1:500 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3691
Practice Address - Country:US
Practice Address - Phone:815-937-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036159040207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program