Provider Demographics
NPI:1801949813
Name:SIOMOPOULOS, VASILIS K (MD, DOB: 06/23/193)
Entity type:Individual
Prefix:DR
First Name:VASILIS
Middle Name:K
Last Name:SIOMOPOULOS
Suffix:
Gender:M
Credentials:MD, DOB: 06/23/193
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1710 RIVERSIDE CT
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2035
Mailing Address - Country:US
Mailing Address - Phone:847-724-6513
Mailing Address - Fax:847-724-6513
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202
Practice Address - Country:US
Practice Address - Phone:847-724-6513
Practice Address - Fax:847-724-6513
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045374261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health