Healthcare Provider Details

I. General information

NPI: 1811080138
Provider Name (Legal Business Name): THEODORE POLIZOS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE SUITE #205
CHICAGO IL
60625-3500
US

IV. Provider business mailing address

PO BOX 95727
HOFFMAN ESTATES IL
60195-0727
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9050
  • Fax: 773-271-9051
Mailing address:
  • Phone: 773-271-9050
  • Fax: 773-271-9051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number016004322
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016004322
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number016004322
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number016004322
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004322
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016004322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: