Healthcare Provider Details

I. General information

NPI: 1013694736
Provider Name (Legal Business Name): VASIM RAJA PANWAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 W IRVING PARK RD
CHICAGO IL
60618-3217
US

IV. Provider business mailing address

502 MIDWEST CLUB PKWY
OAK BROOK IL
60523-2529
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-8200
  • Fax:
Mailing address:
  • Phone: 773-923-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019037000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: