Provider Demographics
NPI:1487636478
Name:WEYBURN, THOMAS D JR (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:WEYBURN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-367-6781
Mailing Address - Fax:847-367-7384
Practice Address - Street 1:525 E CONGRESS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6258
Practice Address - Country:US
Practice Address - Phone:815-759-9260
Practice Address - Fax:815-459-7840
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098952207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360989521Medicaid
ILH51101Medicare UPIN
ILL98518Medicare PIN
IL0360989521Medicaid
ILL98927Medicare PIN