Provider Demographics
NPI:1750389201
Name:WISTENBERG, LEXY (MD)
Entity type:Individual
Prefix:DR
First Name:LEXY
Middle Name:
Last Name:WISTENBERG
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:847-967-5147
Practice Address - Street 1:6131 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2953
Practice Address - Country:US
Practice Address - Phone:847-967-5010
Practice Address - Fax:847-967-5147
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632926OtherBLUE CROSS BLUE SHIELD
ILE99282Medicare UPIN
ILL93603Medicare ID - Type Unspecified