Provider Demographics
NPI:1225013840
Name:PODZAMSKY, JOHN E (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:PODZAMSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MINONK
Mailing Address - State:IL
Mailing Address - Zip Code:61760-1308
Mailing Address - Country:US
Mailing Address - Phone:309-432-2441
Mailing Address - Fax:309-432-3711
Practice Address - Street 1:200 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MINONK
Practice Address - State:IL
Practice Address - Zip Code:61760-1308
Practice Address - Country:US
Practice Address - Phone:309-432-2441
Practice Address - Fax:309-432-3711
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036035223207Q00000X
IL036055223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10215099OtherBCBS
IL036055223Medicaid
C44655Medicare UPIN
IL10215099OtherBCBS
645951Medicare ID - Type UnspecifiedSTREATOR, IL