Basic Information
| Provider Information | |||||||||
| NPI: | 1437461027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDINGER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | BOHM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE STE 1223 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702040 | ||||||||
| FaxNumber: | 8474338727 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 WAUKEGAN RD STE 700 | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600441614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474332620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2010 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 036.134256 | IL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 125058305 | 01 | IL | STATE OF ILLINOIS MEDICAL LICENSE NUMBER | OTHER |