Provider Demographics
NPI:1427271022
Name:THAKADIYIL, ANITA VACHA (MD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:VACHA
Last Name:THAKADIYIL
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 1:11844 WINDING TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1192
Mailing Address - Country:US
Mailing Address - Phone:708-839-1299
Mailing Address - Fax:
Practice Address - Street 1:9760 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3109
Practice Address - Country:US
Practice Address - Phone:708-423-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine