Provider Demographics
NPI:1801877337
Name:NEPOMUCENO, EDILBERTO E JR (MD)
Entity type:Individual
Prefix:DR
First Name:EDILBERTO
Middle Name:E
Last Name:NEPOMUCENO
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 1:1712 LYNWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1932
Mailing Address - Country:US
Mailing Address - Phone:708-957-7187
Mailing Address - Fax:
Practice Address - Street 1:1712 LYNWOOD CT
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1932
Practice Address - Country:US
Practice Address - Phone:708-957-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1124322680OtherGROUP NPI
IL364317999OtherTAX ID
IL806290OtherMEDICARE GROUP PTAN
IL036069957Medicaid
IL566680Medicare ID - Type Unspecified
IL364317999OtherTAX ID
ILIL5686002Medicare UPIN