Provider Demographics
NPI:1265489397
Name:MANTICH, MARLENE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:
Last Name:MANTICH
Suffix:
Gender:F
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:PO BOX 14147
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-0147
Mailing Address - Country:US
Mailing Address - Phone:312-919-9783
Mailing Address - Fax:
Practice Address - Street 1:7722 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1915
Practice Address - Country:US
Practice Address - Phone:312-919-9783
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
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
IL016004721-1Medicaid
IL01606975OtherBLUE SHIELD
ILU58106Medicare UPIN
IL016004721-1Medicaid