Provider Demographics
NPI:1972645588
Name:SECOQUIAN, CESAR M (MD)
Entity Type:Individual
Prefix:DR
First Name:CESAR
Middle Name:M
Last Name:SECOQUIAN
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 1:5 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-9500
Mailing Address - Country:US
Mailing Address - Phone:815-692-3212
Mailing Address - Fax:
Practice Address - Street 1:5 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-9500
Practice Address - Country:US
Practice Address - Phone:815-692-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38604Medicare UPIN