Provider Demographics
NPI:1760563639
Name:VANDENBROOK, AMY WEATHERWAX (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WEATHERWAX
Last Name:VANDENBROOK
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 1:6233 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2317
Mailing Address - Country:US
Mailing Address - Phone:708-749-2020
Mailing Address - Fax:708-749-2069
Practice Address - Street 1:145 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2323
Practice Address - Country:US
Practice Address - Phone:630-971-2020
Practice Address - Fax:630-964-2211
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104595207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001622078OtherBLUS CROSS BLUE SHEILD
IL036104595Medicaid
H37966Medicare UPIN
IL036104595Medicaid