Healthcare Provider Details

I. General information

NPI: 1457007254
Provider Name (Legal Business Name): MR. TYLER GEORGE VAJDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 WEST HURON STREET APARTMENT 1F
CHICAGO IL
60622
US

IV. Provider business mailing address

1738 WEST HURON STREET APARTMENT 1F
CHICAGO IL
60622
US

V. Phone/Fax

Practice location:
  • Phone: 847-504-6530
  • Fax:
Mailing address:
  • Phone: 847-504-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: