Provider Demographics
NPI:1174837140
Name:DAVIDSON, JOANNA WIECZOREK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:WIECZOREK
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JOANNA
Other - Middle Name:LAUREN
Other - Last Name:WIECZOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2035 W CHARLESTON ST
Mailing Address - Street 2:304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4500
Mailing Address - Country:US
Mailing Address - Phone:312-802-0391
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-802-0391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.130953207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine