Healthcare Provider Details

I. General information

NPI: 1184886517
Provider Name (Legal Business Name): DR. GREGG MARTIN DELOSSANTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2839 W MADISON ST
CHICAGO IL
60612-1925
US

IV. Provider business mailing address

39671 TREASURY CTR
CHICAGO IL
60694-9600
US

V. Phone/Fax

Practice location:
  • Phone: 773-533-5500
  • Fax: 773-533-0945
Mailing address:
  • Phone: 773-533-5500
  • Fax: 773-533-0945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: