Provider Demographics
NPI:1831136647
Name:DEURRUTIA, JOSE RAFAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAFAEL
Last Name:DEURRUTIA
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 1:3700 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3824
Mailing Address - Country:US
Mailing Address - Phone:773-542-5203
Mailing Address - Fax:
Practice Address - Street 1:3700 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3824
Practice Address - Country:US
Practice Address - Phone:773-542-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.077752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077752Medicaid
4622394OtherBLUE CROSS
B63375Medicare UPIN
CD0278Medicare PIN
4622394OtherBLUE CROSS
IL036077752Medicaid
K12879Medicare PIN