Healthcare Provider Details

I. General information

NPI: 1265425284
Provider Name (Legal Business Name): SRIGURUNATH VANGIPURAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E WEST RD
CALUMET CITY IL
60409-5415
US

IV. Provider business mailing address

1700 E WEST RD
CALUMET CITY IL
60409-5415
US

V. Phone/Fax

Practice location:
  • Phone: 708-891-3330
  • Fax: 708-891-0904
Mailing address:
  • Phone: 708-891-3330
  • Fax: 708-891-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: