Healthcare Provider Details

I. General information

NPI: 1457500993
Provider Name (Legal Business Name): TARATIP THUPVONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OGDEN AVE
AURORA IL
60504-7222
US

IV. Provider business mailing address

426 SCARBOROUGH RD
VALPARAISO IN
46385-7718
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-6200
  • Fax:
Mailing address:
  • Phone: 219-462-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036121440
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: