Provider Demographics
NPI:1073511135
Name:VUONG, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VUONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 ROOSEVELT RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-545-3760
Mailing Address - Fax:630-545-3769
Practice Address - Street 1:885 ROOSEVELT RD STE 201
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-545-3760
Practice Address - Fax:630-545-3769
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN (GROUP)
IL036110420Medicaid
ILP01053223OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherRAILROAD MEDICARE PTAN (GROUP)
IL206147101OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherRAILROAD MEDICARE PTAN (GROUP)
IL036110420Medicaid