Provider Demographics
NPI:1124412416
Name:STOLBERG, NISSIM (DO)
Entity Type:Individual
Prefix:
First Name:NISSIM
Middle Name:
Last Name:STOLBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9332 TRIPP AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1457
Mailing Address - Country:US
Mailing Address - Phone:773-701-2085
Mailing Address - Fax:
Practice Address - Street 1:2652 W GREENLEAF AVE
Practice Address - Street 2:APT #2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3208
Practice Address - Country:US
Practice Address - Phone:773-701-2085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.0670542080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program