Provider Demographics
NPI:1982665196
Name:FARBOTA, LEO M (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:M
Last Name:FARBOTA
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 1509
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-1509
Mailing Address - Country:US
Mailing Address - Phone:224-238-4160
Mailing Address - Fax:847-783-0599
Practice Address - Street 1:745 FLETCHER DR
Practice Address - Street 2:SUITE 302
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4747
Practice Address - Country:US
Practice Address - Phone:847-695-6600
Practice Address - Fax:847-695-4279
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360708132086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4515536OtherBCBS
IL036070813Medicaid
C41473Medicare UPIN
4515536OtherBCBS
ILIL2305012Medicare PIN
674750Medicare ID - Type Unspecified