Provider Demographics
NPI:1245882315
Name:PETRAK, VANESSA ILIENE (MD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:ILIENE
Last Name:PETRAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VANESSA
Other - Middle Name:ILIENE
Other - Last Name:GRAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 SHILOH CT
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6399
Mailing Address - Country:US
Mailing Address - Phone:310-740-3703
Mailing Address - Fax:
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:630-978-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125075211207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty