Provider Demographics
NPI:1932107430
Name:MEJICANO, RODOLFO J (MD)
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:J
Last Name:MEJICANO
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9641 W 153RD ST
Practice Address - Street 2:48
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3775
Practice Address - Country:US
Practice Address - Phone:708-403-0431
Practice Address - Fax:708-403-0699
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078539Medicaid
IL110228588Medicare PIN
ILE18707Medicare UPIN
ILK13900Medicare PIN
IL036078539Medicaid