Provider Demographics
NPI:1407090491
Name:HERTKO, LEONARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JOSEPH
Last Name:HERTKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13561 ISHNALA DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1885
Mailing Address - Country:US
Mailing Address - Phone:708-349-7112
Mailing Address - Fax:866-253-5694
Practice Address - Street 1:13561 ISHNALA DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-1885
Practice Address - Country:US
Practice Address - Phone:708-349-7112
Practice Address - Fax:866-253-5694
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD89383Medicare UPIN