Provider Demographics
NPI:1972063501
Name:REINOSO, PALOMA LUCIA (MD)
Entity Type:Individual
Prefix:
First Name:PALOMA
Middle Name:LUCIA
Last Name:REINOSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1264
Mailing Address - Country:US
Mailing Address - Phone:312-413-0997
Mailing Address - Fax:
Practice Address - Street 1:1747 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1264
Practice Address - Country:US
Practice Address - Phone:312-413-0997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0361613662084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program