Provider Demographics
NPI:1255327441
Name:TABOR, NICHOLAS M III (DPM)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:M
Last Name:TABOR
Suffix:III
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 1:226 MARQUETTE ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2415
Mailing Address - Country:US
Mailing Address - Phone:815-224-3535
Mailing Address - Fax:815-224-5750
Practice Address - Street 1:226 MARQUETTE ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2415
Practice Address - Country:US
Practice Address - Phone:815-224-3535
Practice Address - Fax:815-224-5750
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004144213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1296560001Medicare NSC
IL1296560002Medicare NSC
IL781591Medicare PIN
IL781590Medicare PIN
ILT39032Medicare UPIN