Provider Demographics
NPI:1366444150
Name:WANDER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WANDER
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 1:908 N ELM ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3625
Mailing Address - Country:US
Mailing Address - Phone:630-325-3310
Mailing Address - Fax:630-325-9163
Practice Address - Street 1:908 N ELM ST
Practice Address - Street 2:SUITE 310
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3625
Practice Address - Country:US
Practice Address - Phone:630-325-3310
Practice Address - Fax:630-325-9163
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042495208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL020008007OtherRR MEDICARE PROVIDER #
IL0002220321OtherBC/BS GROUP #
IL036024295Medicaid
ILCD5773OtherRR MEDICARE GROUP #
ILCD5773OtherRR MEDICARE GROUP #
IL0002220321OtherBC/BS GROUP #