Provider Demographics
NPI:1912016783
Name:DESCH, LARRY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WAYNE
Last Name:DESCH
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 1:9555 S 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3054
Mailing Address - Country:US
Mailing Address - Phone:847-318-9330
Mailing Address - Fax:708-876-1561
Practice Address - Street 1:9555 S 52ND AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3054
Practice Address - Country:US
Practice Address - Phone:847-318-9330
Practice Address - Fax:708-876-1561
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093057208000000X, 2080P0008X
IL036-0930572080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093057OtherSTATE LICENSE
IL14D0419824OtherCLIA