Provider Demographics
NPI:1629208723
Name:HART, JOHN CHARLES (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:HART
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 E WAR MEMORIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-7570
Mailing Address - Country:US
Mailing Address - Phone:309-685-4244
Mailing Address - Fax:309-685-9875
Practice Address - Street 1:300 E WAR MEMORIAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7570
Practice Address - Country:US
Practice Address - Phone:309-685-4244
Practice Address - Fax:309-685-9875
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002951213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist