Healthcare Provider Details

I. General information

NPI: 1467981357
Provider Name (Legal Business Name): KEZIAH M VARGAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W HARRISON ST
CHICAGO IL
60612-3825
US

IV. Provider business mailing address

1650 W HARRISON ST STE 466
CHICAGO IL
60612-3800
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125070651
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: