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General NPI Number Information
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NPI Number | 1285621235
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Entity Type | Organization
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Legal Business Name | DISOMMA FOOT & ANKLE CLINIC PC
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Dates
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Enumeration Date | 10/04/2005
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 1100 LAKE ST STE 248
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City | OAK PARK
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State | IL
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Zip | 60301-1015
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Country | US
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Telephone | 708-383-5554
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Fax | 708-383-9321
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Provider Business Mailing Address
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Address Line | 1100 LAKE ST STE 248
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City | OAK PARK
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State | IL
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Zip | 60301-1015
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Country | US
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Telephone | 708-383-5554
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Fax | 708-383-9321
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY M DISOMMA
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Credential | DPM
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Telephone | 708-383-5554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 016004585
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 060007223
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License Number State | IL
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