Provider Demographics
NPI:1720071970
Name:DEGROOT, MARY D (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1938 E LINCOLN HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3810
Mailing Address - Country:US
Mailing Address - Phone:815-462-9225
Mailing Address - Fax:815-462-5385
Practice Address - Street 1:1938 E LINCOLN HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3810
Practice Address - Country:US
Practice Address - Phone:815-462-9225
Practice Address - Fax:815-462-5385
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00194730OtherRAILROAD MEDICARE
IL01634686OtherBCBS
IL016005141Medicaid
V01817Medicare UPIN
IL01634686OtherBCBS
IL016005141Medicaid
IL210098Medicare PIN