Healthcare Provider Details

I. General information

NPI: 1255771689
Provider Name (Legal Business Name): TOM PAUL VADAKARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2013
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 527
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

12040 NE 128TH ST MS-50
KIRKLAND WA
98034
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 425-899-1920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60937807
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036140761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: