Provider Demographics
NPI:1235142605
Name:BLANK, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BLANK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-4863
Mailing Address - Country:US
Mailing Address - Phone:847-215-1525
Mailing Address - Fax:312-642-9311
Practice Address - Street 1:31 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-4863
Practice Address - Country:US
Practice Address - Phone:847-215-1525
Practice Address - Fax:312-642-9311
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2074213ES0103X
IL016004427213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200820OtherMEDICARE B
IL480015544OtherRAILROAD MEDICARE
IL480015544OtherRAILROAD MEDICARE
FLU36164Medicare UPIN