Healthcare Provider Details

I. General information

NPI: 1053430033
Provider Name (Legal Business Name): VASANTHA SAMALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VASANTHA SAMALA M.D.

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 S 52ND AVE
OAK LAWN IL
60453-3054
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 708-634-0950
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number25622
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25622
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036112098
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036112098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: