ELYSA WIDJAJA MD Medical Doctor License verification

Business Entity

ACTIVE

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****72

License Status

ACTIVE

Business

Title

First Name

ELYSA

Last Name

WIDJAJA

Business Name

ELYSA WIDJAJA MD

Original Issue Date

08/02/2022

Effective Date

04/06/2023

Expiration Date

07/31/2026

City

CHICAGO

State

Zip

60611

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

04/06/2023