Provider Demographics
NPI:1699729186
Name:SUSTENTO-REODICA, NEDJEMA (MD)
Entity type:Individual
Prefix:
First Name:NEDJEMA
Middle Name:
Last Name:SUSTENTO-REODICA
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 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-9797
Mailing Address - Fax:
Practice Address - Street 1:303 E CHICAGO AVE
Practice Address - Street 2:WARD - 6-223 MAIL CODE W127
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4296
Practice Address - Country:US
Practice Address - Phone:312-503-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425026207ZP0105X
IL207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA086250Medicare ID - Type Unspecified
PAI00714Medicare UPIN