Basic Information
Provider Information
NPI: 1003142704
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IGLESIAS
FirstName: ANTONIO
MiddleName: HERNANDO
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2160 S 1ST AVE
Address2:  
City: MAYWOOD
State: IL
PostalCode: 601533328
CountryCode: US
TelephoneNumber: 2154567190
FaxNumber: 2154567308
Practice Location
Address1: 5401 OLD YORK RD
Address2: KLEIN BUILDING, SUITE 405
City: PHILADELPHIA
State: PA
PostalCode: 191413030
CountryCode: US
TelephoneNumber: 2154567190
FaxNumber: 2154567308
Other Information
ProviderEnumerationDate: 10/30/2009
LastUpdateDate: 10/26/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084N0400X036133691ILY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
2084N0400X125-057209ILN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology

No ID Information.


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