Provider Demographics
NPI:1376694570
Name:TRENT, GARY (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:TRENT
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 1:711 TIPPERARY CT APT 2B
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3226
Mailing Address - Country:US
Mailing Address - Phone:312-406-1280
Mailing Address - Fax:773-232-0389
Practice Address - Street 1:711 TIPPERARY CT APT 2B
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-3226
Practice Address - Country:US
Practice Address - Phone:773-445-4525
Practice Address - Fax:773-232-0389
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004438213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001758OtherBLUE CROSSBLUE SHIELD
IL60001758OtherBLUE CROSSBLUE SHIELD
ILU21175Medicare UPIN