Provider Demographics
NPI:1235128075
Name:CHAGOYA, PABLO E (MD)
Entity type:Individual
Prefix:DR
First Name:PABLO
Middle Name:E
Last Name:CHAGOYA
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 1:6545 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2313
Mailing Address - Country:US
Mailing Address - Phone:708-788-0077
Mailing Address - Fax:
Practice Address - Street 1:6545 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2313
Practice Address - Country:US
Practice Address - Phone:708-788-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112461208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-112461-1Medicaid
ILI25650Medicare UPIN
ILK15294/357801Medicare ID - Type Unspecified