Provider Demographics
NPI:1689781742
Name:PEDERSEN, MARITSA T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARITSA
Middle Name:T
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S WIESBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7813
Mailing Address - Country:US
Mailing Address - Phone:630-614-4000
Mailing Address - Fax:630-614-4048
Practice Address - Street 1:2001 S WIESBROOK RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-7813
Practice Address - Country:US
Practice Address - Phone:630-614-4000
Practice Address - Fax:630-614-4048
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080161466OtherRR MEDICARE PTAN (INDIVIDUAL)
IL036096241Medicaid
IL036096241Medicaid
IL592050Medicare ID - Type Unspecified