Provider Demographics
NPI:1740273747
Name:PRIETO, JORGE J (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:J
Last Name:PRIETO
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 1:800 AUSTIN ST
Mailing Address - Street 2:EAST TOWER STE 254
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-475-4550
Mailing Address - Fax:847-475-0482
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:#254
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-475-4550
Practice Address - Fax:847-475-0482
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36058076174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1627223OtherBLUE SHIELD
IL36058076Medicaid
IL200565Medicare ID - Type Unspecified
ILE24430Medicare UPIN