Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 016004988 | IL |
Y | 222Z00000X | Podiatrist | 016004988 | IL |
NPI | 1043490675 |
---|---|
Provider Name | Dr. Kevin M Massard |
First Address | Bartlett, IL 60103-4428 |
Second Address | Bartlett, IL 60103-4428 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2007 |
Last Update Date | 18/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U82775 | (02) | IL |