Provider Demographics
NPI:1447449798
Name:DEZANEK, ROBERT CHARLES (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:DEZANEK
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 1:5916 W HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1905
Mailing Address - Country:US
Mailing Address - Phone:773-283-1911
Mailing Address - Fax:
Practice Address - Street 1:5916 W HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1905
Practice Address - Country:US
Practice Address - Phone:773-283-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060001570OtherBLUE CROSS
IL0060001570OtherBLUE CROSS
IL238230Medicare PIN