Provider Demographics
NPI:1437263076
Name:WYGODNY, JEFFREY BENJAMIN (M,D,)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BENJAMIN
Last Name:WYGODNY
Suffix:
Gender:M
Credentials:M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 W CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3601
Mailing Address - Country:US
Mailing Address - Phone:773-593-4607
Mailing Address - Fax:
Practice Address - Street 1:2128 W CORTEZ ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3601
Practice Address - Country:US
Practice Address - Phone:773-593-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090678207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG64711Medicare UPIN