Provider Demographics
NPI:1508834839
Name:DELGADO-SERRANO, LOURDES (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:DELGADO-SERRANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LOURDES
Other - Middle Name:
Other - Last Name:SERRANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF PEDIATRICS
Practice Address - Street 2:320 E ARMSTRONG
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-624-9587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360830772084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215036OtherBCBS
IL036083077Medicaid
ILIL01CXOtherJOHN DEERE
IL639810Medicare ID - Type UnspecifiedMEDICARE
ILIL01CXOtherJOHN DEERE