Provider Demographics
NPI:1578645313
Name:DERK, JAMES F (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:F
Last Name:DERK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:950 N KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2237
Mailing Address - Country:US
Mailing Address - Phone:815-933-1220
Mailing Address - Fax:815-463-1864
Practice Address - Street 1:1640 WILLOW CIRCLE DR UNIT 200
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0960
Practice Address - Country:US
Practice Address - Phone:815-729-0681
Practice Address - Fax:815-729-1374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004278213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
788322Medicare ID - Type Unspecified
T39122Medicare UPIN
788320Medicare ID - Type Unspecified
788321Medicare ID - Type Unspecified