Provider Demographics
NPI:1093951303
Name:DRS VALDES AND KULEKOWSKIS PODIATRY PC
Entity Type:Organization
Organization Name:DRS VALDES AND KULEKOWSKIS PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELES
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-248-4111
Mailing Address - Street 1:3632 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4715
Mailing Address - Country:US
Mailing Address - Phone:773-248-4111
Mailing Address - Fax:773-248-4450
Practice Address - Street 1:3632 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4715
Practice Address - Country:US
Practice Address - Phone:773-248-4111
Practice Address - Fax:773-248-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005127213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003592Medicaid
IL016005127Medicaid
IL6255030001Medicare NSC
IL016003592Medicaid