Provider Demographics
NPI:1093394975
Name:GUASTELLA, ANGELO FRANK
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:FRANK
Last Name:GUASTELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 W WELLINGTON AVE STE 4800
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5147
Mailing Address - Country:US
Mailing Address - Phone:773-296-7093
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE STE 4800
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL125.077649208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program