Basic Information
Provider Information | |||||||||
NPI: | 1073779179 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUIJANO | ||||||||
FirstName: | CARLA | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 225 E CHICAGO AVE | ||||||||
Address2: | PEDIATRIC RADIOLOGY | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606112991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122273512 | ||||||||
FaxNumber: | 3122279784 | ||||||||
Practice Location | |||||||||
Address1: | 225 E CHICAGO AVE | ||||||||
Address2: | PEDIATRIC RADIOLOGY | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606112991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122273512 | ||||||||
FaxNumber: | 3122279784 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2008 | ||||||||
LastUpdateDate: | 08/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | 036-115570 | IL | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine |   | 2085P0229X | 52803 | WI | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085N0904X | 036115570 | IL | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 036115570 | IL | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 036115570 | IL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
ID | Type | State | Issuer | Description | 1073779179 | 05 | WI |   | MEDICAID |