Provider Demographics
NPI:1538262845
Name:WEISBAUM, JON S (DO)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:WEISBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:OB/GYN
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-383-3140
Practice Address - Fax:217-383-4966
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036069097207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF26084Medicare UPIN
IL6447860011Medicare NSC
IL208905117Medicare PIN
F26084Medicare UPIN
ILIL3270043Medicare PIN