Healthcare Provider Details

I. General information

NPI: 1538236864
Provider Name (Legal Business Name): VANESSA URBAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S LAFOUNTAIN ST
KOKOMO IN
46902-3803
US

IV. Provider business mailing address

1620 BUTTONWOOD CIRLCE #3223
SCHAUMBURG IL
60173
US

V. Phone/Fax

Practice location:
  • Phone: 765-864-5711
  • Fax: 765-864-5712
Mailing address:
  • Phone: 847-952-7460
  • Fax: 847-222-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01066181A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: