Provider Demographics
NPI:1023128121
Name:GVD PODIATRY HEALTHCARE PC
Entity type:Organization
Organization Name:GVD PODIATRY HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-932-8161
Mailing Address - Street 1:1079 SOUTH MYRTLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-5457
Mailing Address - Country:US
Mailing Address - Phone:815-932-8161
Mailing Address - Fax:
Practice Address - Street 1:1079 SOUTH MYRTLE AVENUE
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-5457
Practice Address - Country:US
Practice Address - Phone:815-932-8161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211418Medicare ID - Type UnspecifiedGRP LOCALITY 99
IL211420Medicare ID - Type UnspecifiedGRP LOCALITY 15
ILK16430Medicare PIN
ILU52991Medicare UPIN
ILK16428Medicare PIN