Provider Demographics
NPI:1154426021
Name:MELERO, OTILIO N (MD)
Entity type:Individual
Prefix:
First Name:OTILIO
Middle Name:N
Last Name:MELERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2620
Mailing Address - Country:US
Mailing Address - Phone:773-276-5100
Mailing Address - Fax:
Practice Address - Street 1:4055 N KOLMAR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1917
Practice Address - Country:US
Practice Address - Phone:773-276-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069929Medicaid
IL1635894OtherBLUE SHIELD OF IL
IL203599180OtherEIN
K51208Medicare PIN
ILC46184Medicare UPIN