Provider Demographics
NPI:1194828624
Name:DEZANEK, EUGENE EDMUND (DPM)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:EDMUND
Last Name:DEZANEK
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 1:2 TALCOTT ROAD
Mailing Address - Street 2:SUITE #23
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-692-3700
Mailing Address - Fax:847-692-3838
Practice Address - Street 1:2 TALCOTT ROAD
Practice Address - Street 2:SUITE #23
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-692-3700
Practice Address - Fax:847-692-3838
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36752Medicare UPIN
517980Medicare ID - Type Unspecified