Healthcare Provider Details

I. General information

NPI: 1679648125
Provider Name (Legal Business Name): SHOSHANA ELKIN WASKOW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 WILMETTE AVE
WILMETTE IL
60091-2604
US

IV. Provider business mailing address

1144 WILMETTE AVE
WILMETTE IL
60091-2604
US

V. Phone/Fax

Practice location:
  • Phone: 847-256-6480
  • Fax: 847-256-6482
Mailing address:
  • Phone: 847-256-6480
  • Fax: 847-256-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036095927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: