Provider Demographics
NPI:1083875256
Name:PEACH, ANDREA LUISA (DPM)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LUISA
Last Name:PEACH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 N NORTH BRANCH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2473
Mailing Address - Country:US
Mailing Address - Phone:312-939-5090
Mailing Address - Fax:312-640-4496
Practice Address - Street 1:1229 N NORTH BRANCH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2473
Practice Address - Country:US
Practice Address - Phone:312-939-5090
Practice Address - Fax:312-640-4496
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005323213E00000X
FLPO3449213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist