Provider Demographics
NPI:1417025842
Name:CARDENAS, VICENTE (MD)
Entity Type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:
Last Name:CARDENAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2032 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4116
Mailing Address - Country:US
Mailing Address - Phone:773-247-8855
Mailing Address - Fax:773-247-8896
Practice Address - Street 1:1431 N WESTERN AVE STE 503
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1774
Practice Address - Country:US
Practice Address - Phone:773-772-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103295Medicaid
ILBC7009409OtherDEA
H29736Medicare UPIN
IL621400Medicare ID - Type Unspecified