Provider Demographics
NPI:1053430033
Name:SAMALA, VASANTHA (MD)
Entity type:Individual
Prefix:DR
First Name:VASANTHA
Middle Name:
Last Name:SAMALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VASANTHA
Other - Middle Name:
Other - Last Name:SAMALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:700 E OGDEN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5569
Mailing Address - Country:US
Mailing Address - Phone:630-789-9785
Mailing Address - Fax:630-789-9798
Practice Address - Street 1:700 E OGDEN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5569
Practice Address - Country:US
Practice Address - Phone:630-789-9785
Practice Address - Fax:630-789-9798
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112098207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00694043OtherMEDICARE RAILROAD
IL$$$$$$$$$Medicaid
IL$$$$$$$$$Medicaid
ILP00694043OtherMEDICARE RAILROAD
ILR02692Medicare PIN