Healthcare Provider Details

I. General information

NPI: 1407388648
Provider Name (Legal Business Name): TERRANCE WEEDEN X DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 200
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

1645 W JACKSON BLVD STE 200
CHICAGO IL
60612-3227
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3034
  • Fax:
Mailing address:
  • Phone: 312-942-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-152951
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036.152951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: