Provider Demographics
NPI:1023085172
Name:BANAAD-OMIOTEK, MARIA LOURDES GERALDINE (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA LOURDES
Middle Name:GERALDINE
Last Name:BANAAD-OMIOTEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-1100
Mailing Address - Country:US
Mailing Address - Phone:847-673-5166
Mailing Address - Fax:847-673-5636
Practice Address - Street 1:6201 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1100
Practice Address - Country:US
Practice Address - Phone:847-673-5166
Practice Address - Fax:847-673-5636
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110773Medicaid
IL0001623791OtherBLUE CROSS BLUE SHIELD
I35594Medicare UPIN
IL036110773Medicaid