Provider Demographics
NPI:1114075462
Name:WU, LORENE Y (MD)
Entity Type:Individual
Prefix:
First Name:LORENE
Middle Name:Y
Last Name:WU
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 1:48 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1024
Mailing Address - Country:US
Mailing Address - Phone:708-352-7212
Mailing Address - Fax:708-352-7228
Practice Address - Street 1:48 E 31ST ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1024
Practice Address - Country:US
Practice Address - Phone:708-352-7212
Practice Address - Fax:708-352-7228
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036-089752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG16907Medicare UPIN
IL648400Medicare ID - Type Unspecified