Provider Demographics
NPI:1033868419
Name:WALDVOGEL, VANESSA JO
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:JO
Last Name:WALDVOGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 N CLINTON ST APT 115
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1137
Mailing Address - Country:US
Mailing Address - Phone:320-250-7725
Mailing Address - Fax:
Practice Address - Street 1:9131 W 151ST ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3202
Practice Address - Country:US
Practice Address - Phone:708-323-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127274207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.008947OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION