Provider Demographics
NPI:1952341505
Name:ANDERSON, JOEL R (DPM)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:R
Last Name:ANDERSON
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 1:4920 N CENTRAL AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2338
Mailing Address - Country:US
Mailing Address - Phone:847-358-7005
Mailing Address - Fax:847-358-7065
Practice Address - Street 1:4920 N CENTRAL AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2338
Practice Address - Country:US
Practice Address - Phone:847-358-7005
Practice Address - Fax:847-358-7065
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004882213E00000X
IL016.004882213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6712480001Medicare PIN
IL6712480001Medicare NSC
ILU80336Medicare UPIN