Provider Demographics
NPI:1386600203
Name:ITELD, LAWRENCE H (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:H
Last Name:ITELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 W NORTH AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7138
Mailing Address - Country:US
Mailing Address - Phone:312-757-4505
Mailing Address - Fax:312-757-4605
Practice Address - Street 1:939 W NORTH AVE STE 600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7138
Practice Address - Country:US
Practice Address - Phone:312-757-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108014208200000X
IL036-108014208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI10385Medicare UPIN