Healthcare Provider Details

I. General information

NPI: 1083648992
Provider Name (Legal Business Name): PUNIT VAJARIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GLENWOOD AVE
JOLIET IL
60435-5487
US

IV. Provider business mailing address

1860 PAYSPHERE CIR
CHICAGO IL
60674-0018
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-2121
  • Fax: 815-741-6303
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36-088454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: