Provider Demographics
NPI:1538666078
Name:GIRARDO, CHRISTOPHER BERNARD
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:BERNARD
Last Name:GIRARDO
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 1:422 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2321
Mailing Address - Country:US
Mailing Address - Phone:847-456-6357
Mailing Address - Fax:
Practice Address - Street 1:422 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2321
Practice Address - Country:US
Practice Address - Phone:847-456-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA329823207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program