Provider Demographics
NPI:1821254475
Name:HARMSTON, WESLEY R (DO)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:R
Last Name:HARMSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2638
Mailing Address - Country:US
Mailing Address - Phone:773-434-8026
Mailing Address - Fax:773-434-8107
Practice Address - Street 1:3232 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2638
Practice Address - Country:US
Practice Address - Phone:773-434-8026
Practice Address - Fax:773-434-8107
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-124934207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212960001Medicare PIN
ILF400246002Medicare PIN