MEDICARE: LIJO JOHN DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	135000872	IL

General Provider Information

NPI Number	:	1639552029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIJO JOHN DPM

Provider Business Mailing Address
First Line	:	1108 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3935
Country	:	US
Telephone Number	:	773-722-2712
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3935
Country	:	US
Telephone Number	:	773-722-2712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	07/02/2015

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Directions to “ LIJO JOHN DPM” Practice Location

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