Provider Demographics
NPI:1710934955
Name:PAHOLAK, THOMAS DANIEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DANIEL
Last Name:PAHOLAK
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 1:6374 N LINCOLN AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1283
Mailing Address - Country:US
Mailing Address - Phone:773-866-9800
Mailing Address - Fax:773-866-1733
Practice Address - Street 1:12786 LASALLE LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1020
Practice Address - Country:US
Practice Address - Phone:248-572-3900
Practice Address - Fax:248-572-1277
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004340213E00000X
IL016-004340213ES0131X
MI5901001714213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-004340OtherIL STATE LICENSE
IL0001623503OtherBCBS
IL016-004340Medicaid
IL480027688OtherRAILROAD MEDICARE
IL1208030001Medicare NSC
IL480027688OtherRAILROAD MEDICARE
ILU13617Medicare UPIN