Provider Demographics
NPI:1649344979
Name:EDUKUTHARAYIL, ANTONY (DPM)
Entity type:Individual
Prefix:
First Name:ANTONY
Middle Name:
Last Name:EDUKUTHARAYIL
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 1:314 WILKINS DR
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2465
Mailing Address - Country:US
Mailing Address - Phone:651-707-7046
Mailing Address - Fax:
Practice Address - Street 1:8300 BROADWAY
Practice Address - Street 2:SUITE D1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-750-9497
Practice Address - Fax:219-359-3181
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001091A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist