Provider Demographics
NPI:1790238921
Name:RIVAS-LOPEZ, VANESSA (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:RIVAS-LOPEZ
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 1:1701 W SUPERIOR ST FL 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5646
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:
Practice Address - Street 1:1701 W SUPERIOR ST FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA140307208000000X
IL036.146157208000000X
IL036-146157208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036146157Medicaid