Active NPI
Bernadeta Leegan Wibisono, M.D.
- Pediatrics Physician
- Chicago, IL
National Provider Identifier
1003143504
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 125055427
- Practice address
- 2951 S King Dr Apt 1004
Chicago, IL 60616-3359 - Phone
- (312) 351-1346
- NPI assigned
- Nov 4, 2009
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 125055427 | IL | Primary |
Addresses
Primary practice location
2951 S King Dr Apt 1004
Chicago, IL 60616-3359
Mailing address
2951 S King Dr Apt 1004
Chicago, IL 60616-3359
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 125055427 | IL | MD | Pediatrics Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1257292800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1257292800000",
"number": "1003143504",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2951 S KING DR APT 1004",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606163359"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2951 S KING DR APT 1004",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606163359",
"telephone_number": "312-351-1346"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIBISONO",
"first_name": "BERNADETA",
"middle_name": "LEEGAN",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2009-11-04",
"last_updated": "2009-11-04",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "IL",
"license": "125055427",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.