Provider Demographics
NPI:1134451594
Name:GUSTAVO A . PEDRAZA M.D., LTD
Entity type:Organization
Organization Name:GUSTAVO A . PEDRAZA M.D., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEDRAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-467-4114
Mailing Address - Street 1:23952 S NORTHERN ILLINOIS DR
Mailing Address - Street 2:P.O. BOX 197
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-5184
Mailing Address - Country:US
Mailing Address - Phone:815-467-4114
Mailing Address - Fax:815-467-1774
Practice Address - Street 1:23952 S NORTHERN ILLINOIS DR
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-5184
Practice Address - Country:US
Practice Address - Phone:815-467-4114
Practice Address - Fax:815-467-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076520261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL982330OtherMEDICARE I.D. NUMBER