Provider Demographics
NPI:1376519611
Name:WHEELER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WHEELER
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(FAHEY BLDG., RM. 270)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-5102
Mailing Address - Fax:708-216-1699
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(FAHEY BLDG., RM. 270)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-5102
Practice Address - Fax:708-216-1699
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36066551208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36066551Medicaid
ILL80630Medicare ID - Type Unspecified
C43267Medicare UPIN
IL700660Medicare ID - Type Unspecified