Provider Demographics
NPI:1659323574
Name:WALLIS, DIANE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1919 S HIGHLAND AVE
Mailing Address - Street 2:SUITE B202 ATTN JAN LEWIS
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6153
Mailing Address - Country:US
Mailing Address - Phone:630-268-1102
Mailing Address - Fax:
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-719-4799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036061857207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061857Medicaid
060043700OtherRAILROAD MEDICARE
D15042Medicare UPIN
IL036061857Medicaid