Provider Demographics
NPI:1588620900
Name:ANDRIACCHI, DOMINIC A (DPM)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:A
Last Name:ANDRIACCHI
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 1:9830 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-423-3377
Mailing Address - Fax:
Practice Address - Street 1:6309 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2201
Practice Address - Country:US
Practice Address - Phone:708-499-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000584213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL903660Medicare PIN