Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 016003177 | IL |
Y | 222Z00000X | Podiatrist | 016003177 | IL |
NPI | 1053417154 |
---|---|
Provider Name | Larry David Weisman |
First Address | Glenview, IL 60026-1339 |
Second Address | Glenview, IL 60026-1339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 13/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T37679 | (02) | IL |