=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477565497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONNA IGNACIO VASQUEZ MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 07/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3758 W CHICAGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-235-0626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 E 22ND ST
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-874-2542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIR
-----------------------------------------------------
Name | DONNA I. VASQUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-235-0626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------