Healthcare Provider Details

I. General information

NPI: 1912016783
Provider Name (Legal Business Name): LARRY WAYNE DESCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 S 52ND AVE
OAK LAWN IL
60453-3054
US

IV. Provider business mailing address

9555 S 52ND AVE
OAK LAWN IL
60453-3054
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-9330
  • Fax: 708-876-1561
Mailing address:
  • Phone: 847-318-9330
  • Fax: 708-876-1561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036093057
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number036093057
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number036-093057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: