Provider Demographics
NPI:1649444225
Name:JENNIFER L KALETA DPM, LTD
Entity type:Organization
Organization Name:JENNIFER L KALETA DPM, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANEGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-868-4701
Mailing Address - Street 1:1929 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1011
Mailing Address - Country:US
Mailing Address - Phone:773-868-4701
Mailing Address - Fax:773-868-4702
Practice Address - Street 1:3000 N HALSTED ST STE 625
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5196
Practice Address - Country:US
Practice Address - Phone:773-868-4701
Practice Address - Fax:773-868-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004910213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1633808OtherBC/BS
IL016004910Medicaid
207100OtherMEDICARE ID
IL5048120002OtherDMERC
IL207100Medicare PIN
207100OtherMEDICARE ID
ILU82743Medicare UPIN