Basic Information
| Provider Information | |||||||||
| NPI: | 1427011170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGA | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E IRVING PARK RD | ||||||||
| Address2: | |||||||||
| City: | STREAMWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601073201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307585121 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E IRVING PARK RD | ||||||||
| Address2: | |||||||||
| City: | STREAMWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601073201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307585121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 036073342 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 036073342 | 05 | IL | MEDICAID |