Provider Demographics
NPI:1255514089
Name:GUSTAVO RICARDO SANCHEZ VARGAS MD SC
Entity type:Organization
Organization Name:GUSTAVO RICARDO SANCHEZ VARGAS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:RICARDO
Authorized Official - Last Name:SANCHEZ-VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-966-9701
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098710261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1205965522OtherNPI
IL11308130OtherCAQH
IL4526065OtherBLUE CROSS BLUE SHIELD
IL036098710Medicaid
IL1205965522OtherNPI
IL4526065OtherBLUE CROSS BLUE SHIELD