Healthcare Provider Details

I. General information

NPI: 1124029897
Provider Name (Legal Business Name): INDIRA VAZZALWAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INDIRA CHIRRAVURI

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W. DUGDALE RD.
WAUKEGAN IL
60085
US

IV. Provider business mailing address

6346 N TALMAN AVE SUIT 102
CHICAGO IL
60659-1898
US

V. Phone/Fax

Practice location:
  • Phone: 847-249-0600
  • Fax: 773-262-1184
Mailing address:
  • Phone: 773-262-1300
  • Fax: 773-262-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036109022
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: