Provider Demographics
NPI:1962557686
Name:GUEVARA, AUGUSTO
Entity type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:
Last Name:GUEVARA
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 1:1340 S DAMEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:312-564-4059
Practice Address - Street 1:1340 S DAMEN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1169
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:312-564-4059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-091726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-091726OtherLIC PHYSICIAN