Provider Demographics
NPI:1396806840
Name:DISOMMA, MARY M (DPM)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:DISOMMA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 LAKE ST
Mailing Address - Street 2:SUITE 248
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:708-383-5554
Mailing Address - Fax:708-383-9321
Practice Address - Street 1:1100 LAKE ST
Practice Address - Street 2:SUITE 248
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:708-383-5554
Practice Address - Fax:708-383-9321
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0160045851Medicaid
ILU36162Medicare UPIN
IL211489Medicare ID - Type Unspecified