Provider Demographics
NPI:1013058379
Name:BURGOS, MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:BURGOS
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 1:229 W GRAND AVENUE
Mailing Address - Street 2:SUITE QW
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106
Mailing Address - Country:US
Mailing Address - Phone:630-422-1917
Mailing Address - Fax:630-422-7226
Practice Address - Street 1:229 W GRAND AVENUE
Practice Address - Street 2:SUITE QW
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106
Practice Address - Country:US
Practice Address - Phone:630-422-1917
Practice Address - Fax:630-422-7226
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103673Medicaid