Provider Demographics
NPI:1114992658
Name:VASCONCELLES, CARA E (MD)
Entity Type:Individual
Prefix:DR
First Name:CARA
Middle Name:E
Last Name:VASCONCELLES
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 1:3132 OLD JACKSONVILLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7400
Mailing Address - Country:US
Mailing Address - Phone:217-862-0804
Mailing Address - Fax:217-862-0871
Practice Address - Street 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0804
Practice Address - Fax:217-862-0871
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087654207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087654Medicaid
IL036087654Medicaid
G08946Medicare UPIN