Basic Information
| Provider Information | |||||||||
| NPI: | 1174627269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBREGON | ||||||||
| FirstName: | JACINTO | ||||||||
| MiddleName: | GARCIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11136 WOODSTOCK DR | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084034536 | ||||||||
| FaxNumber: | 7084034537 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153980175 | ||||||||
| FaxNumber: | 8153989587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036060097 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036060097 | 05 | IL | MEDICAID | P00288070 | 01 | PALMETTO GBA RR MEDICARE | OTHER |