Healthcare Provider Details

I. General information

NPI: 1013750348
Provider Name (Legal Business Name): HANS WILLY MAUTONG VASQUEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1901 W HARRISON
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax: 484-218-4916
Mailing address:
  • Phone: 312-864-6000
  • Fax: 312-864-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125083903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: