Provider Demographics
NPI:1356367718
Name:MANQUEN, LOUIS J JR (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:J
Last Name:MANQUEN
Suffix:JR
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 1:801 S MILWAUKEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3199
Mailing Address - Country:US
Mailing Address - Phone:847-990-5389
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE ROAD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3199
Practice Address - Country:US
Practice Address - Phone:847-990-5389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361084192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361084191Medicaid
IL0361084191Medicaid
G75079Medicare UPIN