| Doctor Name: | DR. DOMINGO JUCO DE LA FUENTE |
| NPI Number: | 1033410485 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 036.046875 |
| Business Practice Address: | 1671 Mission Hills Rd Unit 402 Northbrook, IL - 600625735 |
| Business Phone Number: | 8477363003 |
| Business Fax Number: | 8472918237 |
| Mailing Address: | 1671 Mission Hills Rd, Unit 402 NORTHBROOK |
| State: | IL |
| Postal Code: | 600625735 |
| Phone Number: | 8477363003 |
| Fax Number: | 8472918237 |
| NPI Enumeration Date: | 11/16/2010 |
| NPI Last Update Date: | 12/21/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 036.046875 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |