Healthcare Provider Details

I. General information

NPI: 1821006396
Provider Name (Legal Business Name): YEV GRAY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: YEVGENY MANDELBROYT D.P.M.

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

IV. Provider business mailing address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-0140
  • Fax: 312-277-6757
Mailing address:
  • Phone: 773-770-0140
  • Fax: 312-277-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-004841
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number751-025
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-003405
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2002002944
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000848A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number685
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002069
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: