Provider Demographics
NPI:1831107135
Name:VILLASENOR, JERRY JR (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:VILLASENOR
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 1:2300 W. ARMITAGE AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4424
Mailing Address - Country:US
Mailing Address - Phone:708-359-9244
Mailing Address - Fax:847-787-5252
Practice Address - Street 1:2300 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4434
Practice Address - Country:US
Practice Address - Phone:708-359-9244
Practice Address - Fax:847-787-5252
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI48052Medicare UPIN