Provider Demographics
NPI:1750761359
Name:ROMERO GADDI, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ROMERO GADDI
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 1:6500 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4097
Mailing Address - Country:US
Mailing Address - Phone:733-388-1600
Mailing Address - Fax:
Practice Address - Street 1:6500 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4097
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8664
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250671412084P0800X
IL036.1458712084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.145871Medicaid