Provider Demographics
NPI:1851376032
Name:PADOVANO, VINCENZO (MD)
Entity Type:Individual
Prefix:
First Name:VINCENZO
Middle Name:
Last Name:PADOVANO
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 1:890 GARFIELD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3100
Mailing Address - Country:US
Mailing Address - Phone:847-367-0022
Mailing Address - Fax:847-680-0696
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-367-0022
Practice Address - Fax:847-680-0696
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097726207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097726Medicaid
ILF90379Medicare UPIN