Provider Demographics
NPI:1295725901
Name:CHEUNG-O'CARROLL, WAI C (MD)
Entity type:Individual
Prefix:
First Name:WAI
Middle Name:C
Last Name:CHEUNG-O'CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7747 W FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1625
Mailing Address - Country:US
Mailing Address - Phone:773-763-8003
Mailing Address - Fax:
Practice Address - Street 1:1445 N HUNT CLUB RD
Practice Address - Street 2:SUITE 304
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2603
Practice Address - Country:US
Practice Address - Phone:847-855-0100
Practice Address - Fax:847-855-0101
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932117OtherBLUE CROSS BLUE SHIELD
IL04932117OtherBLUE CROSS BLUE SHIELD
K08021Medicare ID - Type Unspecified
IL209451Medicare PIN