Provider Demographics
NPI:1023175536
Name:TORRE, GUSTAVO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:TORRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2627
Mailing Address - Country:US
Mailing Address - Phone:773-772-2020
Mailing Address - Fax:773-772-3320
Practice Address - Street 1:2425 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2627
Practice Address - Country:US
Practice Address - Phone:773-772-2020
Practice Address - Fax:773-772-3320
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL467141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007141Medicaid
IL046007141Medicaid
IL0546230001Medicare NSC