Provider Demographics
NPI:1033664149
Name:YAHUACA, JORGE DIEGO (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:DIEGO
Last Name:YAHUACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:6918 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2337
Practice Address - Country:US
Practice Address - Phone:773-667-3508
Practice Address - Fax:312-962-4986
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125077803207Q00000X
IL036.169108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine