Provider Demographics
NPI:1952824302
Name:GONZALEZ HEREDIA, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:GONZALEZ HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 N WINCHESTER AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1320
Mailing Address - Country:US
Mailing Address - Phone:224-256-0598
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTH FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-257-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.071450208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery