Healthcare Provider Details

I. General information

NPI: 1669644548
Provider Name (Legal Business Name): BANDYK PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18503 TORRENCE AVE
LANSING IL
60438
US

IV. Provider business mailing address

18503 TORRENCE AVE
LANSING IL
60438
US

V. Phone/Fax

Practice location:
  • Phone: 708-474-1900
  • Fax: 708-474-1037
Mailing address:
  • Phone: 708-474-1900
  • Fax: 708-474-1037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-004010
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT JON BANDYK
Title or Position: DR
Credential:
Phone: 708-474-1900