Provider Demographics
NPI:1215125927
Name:HAGAN, VANESSA (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:HAGAN
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 1:4400 W 95TH ST
Mailing Address - Street 2:STE 303
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-423-1300
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:STE 303
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-423-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110316Medicaid
ILK09032Medicare PIN