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General NPI Number Information
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NPI Number | 1407934888
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Entity Type | Organization
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Legal Business Name | DEZANEK PODIATRY CENTER LTD
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 12/26/2014
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Provider Practice Location Address
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Address Line | 5916 W HIGGINS AVE
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City | CHICAGO
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State | IL
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Zip | 60630-1905
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Country | US
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Telephone | 773-283-1911
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Fax |
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Provider Business Mailing Address
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Address Line | 5916 W HIGGINS AVE
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City | CHICAGO
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State | IL
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Zip | 60630-1905
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Country | US
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Telephone | 773-283-1911
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Fax |
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Authorized Official
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Title or Position | CORP PRESIDENT
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Name | DR. ROBERT CHARLES DEZANEK
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Credential | DPM
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Telephone | 773-283-1911
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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 | 016003970
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License Number State | IL
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