Provider Demographics
NPI:1205965522
Name:SANCHEZ-VARGAS, GUSTAVO RICARDO (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:RICARDO
Last Name:SANCHEZ-VARGAS
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 1:523 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3847
Mailing Address - Country:US
Mailing Address - Phone:630-966-9701
Mailing Address - Fax:630-966-9702
Practice Address - Street 1:523 W GALENA BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3847
Practice Address - Country:US
Practice Address - Phone:630-966-9701
Practice Address - Fax:630-966-9702
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098710Medicaid
IL11308130OtherCAQH
IL4526065OtherBLUE CROSS BLUE SHIELD
IL581840Medicare ID - Type Unspecified
IL11308130OtherCAQH