Provider Demographics
NPI:1053417154
Name:WEISMAN, LARRY DAVID (DPM)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DAVID
Last Name:WEISMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 PFINGSTEN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1339
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:866-954-5787
Practice Address - Street 1:2180 PFINGSTEN RD STE 3100
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1339
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:866-954-5787
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37679Medicare UPIN