Provider Demographics
NPI:1003143504
Name:WIBISONO, BERNADETA LEEGAN (MD)
Entity Type:Individual
Prefix:
First Name:BERNADETA
Middle Name:LEEGAN
Last Name:WIBISONO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 S KING DR APT 1004
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2951 S KING DR APT 1004
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3359
Practice Address - Country:US
Practice Address - Phone:312-351-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055427208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics