Provider Demographics
NPI:1639192982
Name:BETTAG, ERIC BALDRIC (DPM)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:BALDRIC
Last Name:BETTAG
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 1:2320 DEAN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1068
Mailing Address - Country:US
Mailing Address - Phone:630-584-4200
Mailing Address - Fax:630-584-4257
Practice Address - Street 1:2320 DEAN ST STE 104
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1068
Practice Address - Country:US
Practice Address - Phone:630-584-4200
Practice Address - Fax:630-584-4257
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL76372Medicare ID - Type Unspecified
ILU67616Medicare UPIN