Provider Demographics
NPI:1639804917
Name:FUDER, JOSHUA T
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:T
Last Name:FUDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1915 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1618
Practice Address - Country:US
Practice Address - Phone:312-674-9132
Practice Address - Fax:312-674-9392
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070026833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist