Provider Demographics
NPI:1548732738
Name:MONTES DE OCA, MANUEL JR (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:MONTES DE OCA
Suffix:JR
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 1:625 W MADISON ST APT 3711
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3153 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2809
Practice Address - Country:US
Practice Address - Phone:773-395-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2024-02-27
Deactivation Date:2022-02-23
Deactivation Code:
Reactivation Date:2022-03-29
Provider Licenses
StateLicense IDTaxonomies
IL036.159998207R00000X
NY315008207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program