Provider Demographics
NPI:1215515143
Name:WEISE, LORELA BERBERI (MD)
Entity type:Individual
Prefix:DR
First Name:LORELA
Middle Name:BERBERI
Last Name:WEISE
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 1:1133 SOUTH BLVD APT 723
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3286
Mailing Address - Country:US
Mailing Address - Phone:602-503-2842
Mailing Address - Fax:
Practice Address - Street 1:1715 E COPPER ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-3119
Practice Address - Country:US
Practice Address - Phone:602-503-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.078704208600000X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery