Provider Demographics
NPI:1356441943
Name:WESLY, OSVALDO H (MD)
Entity Type:Individual
Prefix:DR
First Name:OSVALDO
Middle Name:H
Last Name:WESLY
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 1:105 S. AMOS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704
Mailing Address - Country:US
Mailing Address - Phone:217-546-7100
Mailing Address - Fax:217-546-7111
Practice Address - Street 1:105 S. AMOS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-546-7100
Practice Address - Fax:217-546-7111
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-089289207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089289Medicaid
E91935Medicare UPIN
K24224Medicare ID - Type Unspecified