Provider Demographics
NPI:1215043310
Name:PODOMEDIK LLC
Entity Type:Organization
Organization Name:PODOMEDIK LLC
Other - Org Name:CARMEN SEBASTIAN-NOVELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ-ESPINDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-520-4513
Mailing Address - Street 1:2634 GRAND AVE STE 102A
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2459
Mailing Address - Country:US
Mailing Address - Phone:847-249-3888
Mailing Address - Fax:
Practice Address - Street 1:2634 GRAND AVE STE 102A
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2459
Practice Address - Country:US
Practice Address - Phone:847-249-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI911025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43241500Medicaid
30-6095164OtherTAX ID
IL213464Medicare ID - Type UnspecifiedGROUP NUMBER
WI43241500Medicaid
30-6095164OtherTAX ID
WI000180083Medicare UPIN
WI000080083Medicare ID - Type UnspecifiedGROUP NUMBER