Provider Demographics
NPI:1669538641
Name:ELLIOTT-PEARSON, WANDA (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ELLIOTT-PEARSON
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 1:2315 E 93RD ST
Mailing Address - Street 2:SUITE440
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3936
Mailing Address - Country:US
Mailing Address - Phone:773-768-2535
Mailing Address - Fax:773-374-4079
Practice Address - Street 1:2315 E 93RD ST
Practice Address - Street 2:SUITE440
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3936
Practice Address - Country:US
Practice Address - Phone:773-768-2535
Practice Address - Fax:773-374-4079
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL18381Medicare ID - Type Unspecified
ILE30337Medicare UPIN