Provider Demographics
NPI:1619924248
Name:VASANWALA, SALIL R (MD)
Entity Type:Individual
Prefix:DR
First Name:SALIL
Middle Name:R
Last Name:VASANWALA
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 1:3540 TOULOUSE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4558
Mailing Address - Country:US
Mailing Address - Phone:815-936-9440
Mailing Address - Fax:815-936-9308
Practice Address - Street 1:19 HERITAGE DR
Practice Address - Street 2:STE104
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1369
Practice Address - Country:US
Practice Address - Phone:815-936-9440
Practice Address - Fax:815-936-9308
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL329430Medicare ID - Type Unspecified
ILF61479Medicare UPIN