Provider Demographics
NPI:1316045206
Name:LAYCOCK, LORI L (DO)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:L
Last Name:LAYCOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S WIESBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7813
Mailing Address - Country:US
Mailing Address - Phone:630-614-4000
Mailing Address - Fax:630-614-4048
Practice Address - Street 1:2001 S WIESBROOK RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189
Practice Address - Country:US
Practice Address - Phone:630-614-4000
Practice Address - Fax:630-614-4048
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00409499OtherRR MEDICARE (INDIVIDUAL)
IL592050OtherMEDICARE PTAN (GROUP)
IL03000801Medicaid
ILK39248OtherMEDICARE PTAN (INDIVIDUAL)
IL592050OtherMEDICARE PTAN (GROUP)