Provider Demographics
NPI:1700954294
Name:WALO, MIROSLAW JAN (MD)
Entity type:Individual
Prefix:DR
First Name:MIROSLAW
Middle Name:JAN
Last Name:WALO
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:PO BOX 7053
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60204-7053
Mailing Address - Country:US
Mailing Address - Phone:847-668-4415
Mailing Address - Fax:847-324-4303
Practice Address - Street 1:1010 CENTRAL AVE UNIT 4A
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2681
Practice Address - Country:US
Practice Address - Phone:847-324-4300
Practice Address - Fax:847-324-4303
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360938642084P0800X
IL036-0938642084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093864Medicaid
ILG34910Medicare UPIN
IL580340Medicare ID - Type Unspecified