Healthcare Provider Details

I. General information

NPI: 1194937169
Provider Name (Legal Business Name): WITHMAN H HARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 W MAIN ST SUITE 200
ST CHARLES IL
60175-1000
US

IV. Provider business mailing address

PO BOX 657
ST CHARLES IL
60174-0657
US

V. Phone/Fax

Practice location:
  • Phone: 630-897-6044
  • Fax: 630-897-0180
Mailing address:
  • Phone: 630-897-6044
  • Fax: 630-897-0180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.118117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: