Provider Demographics
NPI:1871638338
Name:LOME, LEON GERSHON (MD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:GERSHON
Last Name:LOME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 AUSTIN ST
Mailing Address - Street 2:SUITE 457E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-328-8884
Mailing Address - Fax:847-328-9129
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:SUITE 457E
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-328-8884
Practice Address - Fax:847-328-9129
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036039465208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039465Medicaid
IL036039465Medicaid
ILL30595Medicare PIN