Healthcare Provider Details

I. General information

NPI: 1053417154
Provider Name (Legal Business Name): LARRY DAVID WEISMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 PFINGSTEN RD STE 3100
GLENVIEW IL
60026-1339
US

IV. Provider business mailing address

2180 PFINGSTEN RD
GLENVIEW IL
60026-1339
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax: 866-954-5787
Mailing address:
  • Phone: 847-866-7846
  • Fax: 866-954-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: