Provider Demographics
NPI:1588726277
Name:VONDRAK, ROSS G (LMT, NCTMB)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:G
Last Name:VONDRAK
Suffix:
Gender:M
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3512
Mailing Address - Country:US
Mailing Address - Phone:708-352-7782
Mailing Address - Fax:
Practice Address - Street 1:5707 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3512
Practice Address - Country:US
Practice Address - Phone:708-352-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist