Provider Demographics
NPI:1184653883
Name:WARDLOW, JESSE G (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:G
Last Name:WARDLOW
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 1:11 SALT CREEK LN STE 101
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3032
Mailing Address - Country:US
Mailing Address - Phone:630-789-3110
Mailing Address - Fax:
Practice Address - Street 1:11 SALT CREEK LN STE 101
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3032
Practice Address - Country:US
Practice Address - Phone:630-789-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093003207YX0602X, 207YX0901X, 208D00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093003Medicaid
IL036093003Medicaid
IL036093003Medicaid
ILF57948Medicare UPIN