Basic Information
Provider Information | |||||||||
NPI: | 1093345340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAUL | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | JADUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JADUE GONZALEZ | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | CECILIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, MS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1500 S. CALIFORNIA | ||||||||
Address2: | #F1008 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732576025 | ||||||||
FaxNumber: | 7732576045 | ||||||||
Practice Location | |||||||||
Address1: | 1500 S. CALIFORNIA AVE | ||||||||
Address2: | #F1008 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732576025 | ||||||||
FaxNumber: | 7732576045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2020 | ||||||||
LastUpdateDate: | 08/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125075968 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.