Provider Demographics
NPI:1609940139
Name:HOBERMAN, GARY JAY (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JAY
Last Name:HOBERMAN
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 1:4201 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1601
Mailing Address - Country:US
Mailing Address - Phone:312-618-1208
Mailing Address - Fax:
Practice Address - Street 1:4201 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1601
Practice Address - Country:US
Practice Address - Phone:312-618-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003368213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003368Medicaid
IL685970Medicare PIN
T37834Medicare UPIN
IL016003368Medicaid