Provider Demographics
NPI:1427676113
Name:EDWARDS, WALLIS OLIVIA (MD)
Entity type:Individual
Prefix:
First Name:WALLIS
Middle Name:OLIVIA
Last Name:EDWARDS
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 1:1324 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2161
Mailing Address - Country:US
Mailing Address - Phone:847-599-4856
Mailing Address - Fax:
Practice Address - Street 1:2723 SHERIDAN RD STE C
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2616
Practice Address - Country:US
Practice Address - Phone:847-360-4260
Practice Address - Fax:847-360-4159
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036163896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program