Healthcare Provider Details

I. General information

NPI: 1932513934
Provider Name (Legal Business Name): DAPHNE L VANDER ROEST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DAPHNE POLYMNIA LAMBROPOULOS

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-065354
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number336.103699
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.142322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: