Provider Demographics
NPI:1457402109
Name:BREADON, JONITH Y (MD)
Entity Type:Individual
Prefix:DR
First Name:JONITH
Middle Name:Y
Last Name:BREADON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W FULTON MARKET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1222
Mailing Address - Country:US
Mailing Address - Phone:312-733-2492
Mailing Address - Fax:312-733-2498
Practice Address - Street 1:1009 W FULTON MARKET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1222
Practice Address - Country:US
Practice Address - Phone:312-733-2492
Practice Address - Fax:312-733-2498
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC89174Medicare UPIN