Provider Demographics
NPI:1356352710
Name:WALLY, LAURA L (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WALLY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:711 W NORTH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1042
Mailing Address - Country:US
Mailing Address - Phone:312-337-1982
Mailing Address - Fax:
Practice Address - Street 1:4999 OLD ORCHARD SHOPPING CENTER, STE F12 & F13
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077
Practice Address - Country:US
Practice Address - Phone:312-219-2230
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK29644Medicare PIN
H74479Medicare UPIN
ILK29643Medicare PIN