Provider Demographics
NPI:1407581986
Name:TAMAYO, LUCIANO A (MD)
Entity type:Individual
Prefix:DR
First Name:LUCIANO
Middle Name:A
Last Name:TAMAYO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUCIANO
Other - Middle Name:A
Other - Last Name:TAMAYO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MEDICAL DOCTOR
Mailing Address - Street 1:645 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-5059
Mailing Address - Country:US
Mailing Address - Phone:773-626-4300
Mailing Address - Fax:
Practice Address - Street 1:645 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-5059
Practice Address - Country:US
Practice Address - Phone:773-626-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0810292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry