Healthcare Provider Details

I. General information

NPI: 1912465527
Provider Name (Legal Business Name): ANA CRISTINA WAGENER-SOBRERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1985 N MANNHEIM RD
MELROSE PARK IL
60160-1012
US

IV. Provider business mailing address

3207 S LITUANICA AVE
CHICAGO IL
60608-6624
US

V. Phone/Fax

Practice location:
  • Phone: 708-834-7566
  • Fax: 312-872-7368
Mailing address:
  • Phone: 708-834-7566
  • Fax: 312-872-7368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.169016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: