Provider Demographics
NPI:1184331522
Name:WIDJAJA, ELYSA (MD)
Entity type:Individual
Prefix:DR
First Name:ELYSA
Middle Name:
Last Name:WIDJAJA
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:LURIE CHILDREN'S HOSPITAL
Mailing Address - Street 2:225 E. CHICAGO AVENUE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-227-3475
Mailing Address - Fax:312-227-9783
Practice Address - Street 1:LURIE CHILDREN'S HOSPITAL
Practice Address - Street 2:225 E. CHICAGO AVENUE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-3475
Practice Address - Fax:312-227-9783
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2023-03-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL0361617472085R0202X
IL036.1617472085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology