Provider Demographics
NPI:1841639069
Name:DUPAGE FOOT AND ANKLE, LLC
Entity type:Organization
Organization Name:DUPAGE FOOT AND ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-842-8891
Mailing Address - Street 1:1525 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3583
Mailing Address - Country:US
Mailing Address - Phone:630-538-3668
Mailing Address - Fax:630-480-7423
Practice Address - Street 1:1525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3583
Practice Address - Country:US
Practice Address - Phone:630-538-3668
Practice Address - Fax:630-480-7423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004441261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004441Medicaid
IL016-004441OtherLICENSE NUMBER
IL016-004441OtherLICENSE NUMBER
IL7351090001Medicare NSC
ILBN2320896OtherDEA