=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083698526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AXEL VARGAS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2005
-----------------------------------------------------
Last Update Date | 10/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 WILMETTE AVE SUITE # 2G
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-951-6471
-----------------------------------------------------
Fax | 888-961-6471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1049 FOREST AVE
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-961-6471
-----------------------------------------------------
Fax | 888-961-6471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 036089572
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 36-089572
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------