Healthcare Provider Details

I. General information

NPI: 1932454279
Provider Name (Legal Business Name): PODOMEDIK CLINICS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N GREENLEAF ST STE 1
GURNEE IL
60031-3341
US

IV. Provider business mailing address

159 N GREENLEAF ST STE 1
GURNEE IL
60031-3341
US

V. Phone/Fax

Practice location:
  • Phone: 847-249-3888
  • Fax: 847-574-7477
Mailing address:
  • Phone: 847-249-3888
  • Fax: 847-574-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number91125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number016005265
License Number StateIL

VIII. Authorized Official

Name: GERARDO PEREZ ESPINDOLA
Title or Position: OWNER/PROVIDER
Credential: DPM
Phone: 414-719-4799