Healthcare Provider Details

I. General information

NPI: 1649826512
Provider Name (Legal Business Name): JEFFREY VARGHESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W POLK ST
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

1950 W POLK ST
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-0393
  • Fax:
Mailing address:
  • Phone: 312-864-0393
  • Fax: 312-864-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125082535
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125082535
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: