Healthcare Provider Details

I. General information

NPI: 1124004262
Provider Name (Legal Business Name): HUMBERTO VERGARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 N WESTERN AVE SUITE 205
CHICAGO IL
60622-1797
US

IV. Provider business mailing address

1431 N WESTERN AVE SUITE 205
CHICAGO IL
60622-1797
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-4811
  • Fax: 773-278-5920
Mailing address:
  • Phone: 773-278-4811
  • Fax: 773-278-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036-072013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: