Provider Demographics
NPI:1851792600
Name:ISAAC, VINCENT PAUL (DPT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:PAUL
Last Name:ISAAC
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2921
Mailing Address - Country:US
Mailing Address - Phone:773-698-6659
Mailing Address - Fax:
Practice Address - Street 1:2906 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2921
Practice Address - Country:US
Practice Address - Phone:773-698-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-021196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01446057OtherRR MEDICARE
ILF400182364Medicare PIN