Provider Demographics
NPI:1952358574
Name:ISENSTADT, GARRY S (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:S
Last Name:ISENSTADT
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 1:2831 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7403
Mailing Address - Country:US
Mailing Address - Phone:773-772-4440
Mailing Address - Fax:773-772-4461
Practice Address - Street 1:2831 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7403
Practice Address - Country:US
Practice Address - Phone:773-772-4440
Practice Address - Fax:773-772-4461
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016002700Medicaid
ILT36912Medicare UPIN
IL213713Medicare PIN