Healthcare Provider Details

I. General information

NPI: 1922360577
Provider Name (Legal Business Name): NATALIE NICOLE DOMEK DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 W HIGGINS AVE
CHICAGO IL
60656-2161
US

IV. Provider business mailing address

6560 W HIGGINS AVE
CHICAGO IL
60656-2161
US

V. Phone/Fax

Practice location:
  • Phone: 773-775-0300
  • Fax:
Mailing address:
  • Phone: 773-775-0300
  • Fax: 773-775-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: