Provider Demographics
NPI:1932167228
Name:WILLOWBROOK PODIATRY INC
Entity Type:Organization
Organization Name:WILLOWBROOK PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANTVIT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-887-9221
Mailing Address - Street 1:62 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:62 63RD ST
Practice Address - Street 2:
Practice Address - City:WILLOW BROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2982
Practice Address - Country:US
Practice Address - Phone:630-887-9221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL004656213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0732240001OtherDMERC # WITH PPG
ILDG8105OtherRAIL ROAD MEDICARE
IL0002219563OtherBCBS
IL016004656Medicaid
IN200136470AMedicaid
IL0002219563OtherBCBS
0732240001OtherDMERC # WITH PPG