Provider Demographics
NPI:1891716981
Name:GOSHKO, VADIM (DPM)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:GOSHKO
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 1:5501 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641
Mailing Address - Country:US
Mailing Address - Phone:773-205-0106
Mailing Address - Fax:773-205-8107
Practice Address - Street 1:5501 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641
Practice Address - Country:US
Practice Address - Phone:773-205-0106
Practice Address - Fax:773-205-8107
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004989213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004989Medicaid
U82385Medicare UPIN
IL016004989Medicaid