Basic Information
| Provider Information | |||||||||
| NPI: | 1982665196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARBOTA | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1509 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601211509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2242384160 | ||||||||
| FaxNumber: | 8477830599 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 FLETCHER DR | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476956600 | ||||||||
| FaxNumber: | 8476954279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036070813 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 036070813 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4515536 | 01 | BCBS | OTHER | 036070813 | 05 | IL | MEDICAID |