Healthcare Provider Details

I. General information

NPI: 1447109830
Provider Name (Legal Business Name): TIMOTHY VAZQUEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5207 MAIN ST
DOWNERS GROVE IL
60515-4652
US

IV. Provider business mailing address

POB 7132960
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 630-435-9888
  • Fax: 630-963-1524
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-012127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: