Provider Demographics
NPI:1952690422
Name:DADIVAS, JESUS RENE II (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:RENE
Last Name:DADIVAS
Suffix:II
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 1:8430 W PETER TER
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1852
Mailing Address - Country:US
Mailing Address - Phone:847-825-3906
Mailing Address - Fax:
Practice Address - Street 1:730 S DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1838
Practice Address - Country:US
Practice Address - Phone:312-588-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine