Provider Demographics
NPI:1700864337
Name:LISSOOS, TREVOR WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:WARREN
Last Name:LISSOOS
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 1:1475 E BELVIDERE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:847-295-0013
Mailing Address - Fax:847-295-1574
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:847-295-0013
Practice Address - Fax:847-295-1574
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL83881Medicare ID - Type Unspecified
ILF54679Medicare UPIN