Provider Demographics
NPI:1134193121
Name:SUEBLINVONG, VITHIDA (MD)
Entity type:Individual
Prefix:
First Name:VITHIDA
Middle Name:
Last Name:SUEBLINVONG
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 1:840 S WOOD ST
Mailing Address - Street 2:M/C 856
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-6605
Mailing Address - Fax:312-413-3373
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:M/C 856
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-6605
Practice Address - Fax:312-413-3373
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360993892080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36099389Medicaid
ILK09585Medicaid
IN200200420Medicare ID - Type Unspecified
ILK09585Medicaid
H70615Medicare UPIN