Provider Demographics
NPI:1952795254
Name:VANDREVALA, MALCOLM MARAZBAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:MARAZBAN
Last Name:VANDREVALA
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8901 GOLF RD STE 301
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4029
Practice Address - Country:US
Practice Address - Phone:847-318-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1454422084P0800X, 2084P0804X
IL1250668812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry