Healthcare Provider Details

I. General information

NPI: 1992716914
Provider Name (Legal Business Name): CARL JOHN CORTESE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 VISA DR STE 5B
NORMAL IL
61761-6160
US

IV. Provider business mailing address

1607 VISA DR STE 5B
NORMAL IL
61761-6160
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-3000
  • Fax: 309-452-3668
Mailing address:
  • Phone: 309-452-3000
  • Fax: 309-452-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-002598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: