Provider Demographics
NPI:1831243831
Name:VERGARA-RODRIGUEZ, PAMELA TERESA (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:TERESA
Last Name:VERGARA-RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 W LILL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2309
Mailing Address - Country:US
Mailing Address - Phone:312-371-2026
Mailing Address - Fax:773-404-0026
Practice Address - Street 1:2020 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3741
Practice Address - Country:US
Practice Address - Phone:312-572-4753
Practice Address - Fax:312-572-4597
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111630207R00000X, 2084A0401X
IL036-116302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17490Medicare UPIN