Provider Demographics
NPI:1144370990
Name:HENRIQUEZ, ROLANDO (MD)
Entity type:Individual
Prefix:
First Name:ROLANDO
Middle Name:
Last Name:HENRIQUEZ
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 1:229 W GRAND AVENUE
Mailing Address - Street 2:SUITE R
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106
Mailing Address - Country:US
Mailing Address - Phone:630-238-9235
Mailing Address - Fax:630-238-0426
Practice Address - Street 1:1841 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1901
Practice Address - Country:US
Practice Address - Phone:630-238-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2205538OtherBCBS OF ILLINOIS
IL036087152Medicaid
IL363950044OtherTAX ID
IL036087152Medicaid
IL2205538OtherBCBS OF ILLINOIS
IL352610Medicare ID - Type Unspecified