Provider Demographics
NPI:1205577483
Name:VAHTRA, MADLI (DO)
Entity type:Individual
Prefix:DR
First Name:MADLI
Middle Name:
Last Name:VAHTRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 N WELLS ST APT 1606
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6015
Mailing Address - Country:US
Mailing Address - Phone:312-656-0965
Mailing Address - Fax:
Practice Address - Street 1:1555 BARRINGTON RD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1019
Practice Address - Country:US
Practice Address - Phone:312-656-0965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.079916207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program