Healthcare Provider Details

I. General information

NPI: 1356441943
Provider Name (Legal Business Name): OSVALDO H WESLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S AMOS AVE
SPRINGFIELD IL
62704-1528
US

IV. Provider business mailing address

105 S. AMOS AVE
SPRINGFIELD IL
62704
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-7100
  • Fax: 217-546-7111
Mailing address:
  • Phone: 217-546-7100
  • Fax: 217-546-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036-089289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: