Provider Demographics
NPI:1568430767
Name:VESTA, ERNEST (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:VESTA
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 1:3511 LIZUM CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7318
Mailing Address - Country:US
Mailing Address - Phone:815-877-5287
Mailing Address - Fax:815-877-5969
Practice Address - Street 1:695 N KELLOGG ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2807
Practice Address - Country:US
Practice Address - Phone:309-343-8131
Practice Address - Fax:309-343-2393
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44524Medicare UPIN