Provider Demographics
NPI:1124029897
Name:VAZZALWAR, INDIRA (MD)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:VAZZALWAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:INDIRA
Other - Middle Name:
Other - Last Name:CHIRRAVURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6346 N TALMAN AVE
Mailing Address - Street 2:SUIT 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1898
Mailing Address - Country:US
Mailing Address - Phone:773-262-1300
Mailing Address - Fax:773-262-1184
Practice Address - Street 1:1401 W. DUGDALE RD.
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-249-0600
Practice Address - Fax:773-262-1184
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361090222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH88531Medicare UPIN