Provider Demographics
NPI:1679067672
Name:PERNIA-CUBEROS, JULIO DIOSMAN (MD)
Entity type:Individual
Prefix:DR
First Name:JULIO
Middle Name:DIOSMAN
Last Name:PERNIA-CUBEROS
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 1:2001 S CALIFORNIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2486
Mailing Address - Country:US
Mailing Address - Phone:773-584-6200
Mailing Address - Fax:844-285-1003
Practice Address - Street 1:3059 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4131
Practice Address - Country:US
Practice Address - Phone:773-584-6200
Practice Address - Fax:844-285-1003
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
IL036156493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036156493Medicaid