Basic Information
| Provider Information | |||||||||
| NPI: | 1417025842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDENAS | ||||||||
| FirstName: | VICENTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2032 W CERMAK RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732478855 | ||||||||
| FaxNumber: | 7732478896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 N WESTERN AVE STE 503 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737729121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036103295 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036103295 | 05 | IL | MEDICAID | BC7009409 | 01 | IL | DEA | OTHER |