Provider Demographics
NPI:1164519526
Name:AYZENBERG, LEONID (MD)
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:
Last Name:AYZENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E. RAND RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1508
Mailing Address - Country:US
Mailing Address - Phone:847-537-6800
Mailing Address - Fax:847-556-8847
Practice Address - Street 1:303 E. RAND RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1508
Practice Address - Country:US
Practice Address - Phone:847-537-6800
Practice Address - Fax:847-556-8847
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095153207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1622332OtherBC & BS PROVIDER NUMBER
IL364232115OtherTAX ID
IL036095153Medicaid
IL036095153Medicaid
ILG68450Medicare UPIN
IL1312620001Medicare NSC