Provider Demographics
NPI:1437461027
Name:WALDINGER, JASON BOHM (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:BOHM
Last Name:WALDINGER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-570-2040
Mailing Address - Fax:847-433-8727
Practice Address - Street 1:71 WAUKEGAN RD STE 700
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1614
Practice Address - Country:US
Practice Address - Phone:847-433-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.134256207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125058305OtherSTATE OF ILLINOIS MEDICAL LICENSE NUMBER