Provider Demographics
NPI:1154407039
Name:MALDONADO, RITA WALESKA (MD)
Entity type:Individual
Prefix:DR
First Name:RITA
Middle Name:WALESKA
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15133 N DENDRON ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-7458
Mailing Address - Country:US
Mailing Address - Phone:217-821-1924
Mailing Address - Fax:
Practice Address - Street 1:1011 FORD AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1701
Practice Address - Country:US
Practice Address - Phone:217-347-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR002#7829Medicare PIN