Provider Demographics
NPI:1437479839
Name:SIMONOVICH, JOHN RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:SIMONOVICH
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 1:259 E ERIE ST STE 2230
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3370
Mailing Address - Country:US
Mailing Address - Phone:312-695-6800
Mailing Address - Fax:312-926-8267
Practice Address - Street 1:259 E ERIE ST
Practice Address - Street 2:SUITE 2230
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-926-6000
Practice Address - Fax:312-926-8267
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005484213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL522620914Medicare PIN