Provider Demographics
NPI:1972567717
Name:MYSIAK, WALDEMAR (MD)
Entity type:Individual
Prefix:DR
First Name:WALDEMAR
Middle Name:
Last Name:MYSIAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 S MILWAUKEE AVE
Mailing Address - Street 2:SUITE 261
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3253
Mailing Address - Country:US
Mailing Address - Phone:847-281-1100
Mailing Address - Fax:847-281-1300
Practice Address - Street 1:755 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 261
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3253
Practice Address - Country:US
Practice Address - Phone:847-281-1100
Practice Address - Fax:847-281-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099938Medicaid
IL04932174OtherBCBS NUMBER
IL364406567OtherTAX ID
ILH11541Medicare UPIN
IL364406567OtherTAX ID