Healthcare Provider Details

I. General information

NPI: 1588243984
Provider Name (Legal Business Name): ERSTA PUTRA FERRYANTO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 WAUKEGAN RD STE FGH
GLENVIEW IL
60025-1759
US

IV. Provider business mailing address

2200 WAUKEGAN RD STE FGH
GLENVIEW IL
60025-1759
US

V. Phone/Fax

Practice location:
  • Phone: 847-558-7670
  • Fax: 888-202-3110
Mailing address:
  • Phone: 847-558-7670
  • Fax: 888-202-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016006049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: