Provider Demographics
NPI:1922272830
Name:ALZATE, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:ALZATE
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 1:712 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3279
Mailing Address - Country:US
Mailing Address - Phone:847-362-1848
Mailing Address - Fax:847-362-3351
Practice Address - Street 1:712 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3279
Practice Address - Country:US
Practice Address - Phone:847-362-1848
Practice Address - Fax:847-362-3351
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121596207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121596Medicaid
IL209425003Medicare PIN
IL036121596Medicaid