Healthcare Provider Details

I. General information

NPI: 1124053269
Provider Name (Legal Business Name): JENNIFER VARGAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 CERMAK RD
BERWYN IL
60402
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 773-254-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number036113015
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-113015
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: