Healthcare Provider Details

I. General information

NPI: 1629560339
Provider Name (Legal Business Name): MANISH PANDYA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640
US

IV. Provider business mailing address

5038 JARVIS AVE
SKOKIE IL
60077-3312
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 847-800-4530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number135001025
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: