Provider Demographics
NPI:1659364396
Name:AMEZCUA-PATINO, LAURO (MD)
Entity type:Individual
Prefix:
First Name:LAURO
Middle Name:
Last Name:AMEZCUA-PATINO
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 1:4055 W CHANDLER BLVD
Mailing Address - Street 2:SUITE #5
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3700
Mailing Address - Country:US
Mailing Address - Phone:480-464-4431
Mailing Address - Fax:480-464-2338
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT64292084P0800X
WAMD615300962084P0800X
AZ179002084P0800X
WI40232084P0800X
DEC1-00267642084P0800X
IL0361687022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ17900OtherMEDICAL LICENSE
TXT6429OtherTEXAS MEDICAL BOARD
AZ17900OtherMEDICAL LICENSE