Healthcare Provider Details

I. General information

NPI: 1639325681
Provider Name (Legal Business Name): ASHLEY VAVRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611
US

IV. Provider business mailing address

680 N LAKE SHORE DR
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-2714
  • Fax:
Mailing address:
  • Phone: 312-695-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036121509
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0054184
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036121509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: