Provider Demographics
NPI:1114039369
Name:MACK, TODD M (DPM)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:M
Last Name:MACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MONROE ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:708-937-2988
Mailing Address - Fax:
Practice Address - Street 1:18 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:773-253-3933
Practice Address - Fax:773-437-6780
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI892-025213ES0103X
IL016005154213ES0103X
CA5325213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005154Medicaid
WI43267600Medicaid
IL01634612OtherBLUE CROSS BLUE SHIELD
WI43237200Medicaid
IL5310850001Medicare NSC
IL01634612OtherBLUE CROSS BLUE SHIELD
IL016005154Medicaid
WI0001Medicare ID - Type Unspecified
WI43267600Medicaid