Provider Demographics
NPI:1679957914
Name:POTACH-MOON PODIATRY GROUP, LLC
Entity type:Organization
Organization Name:POTACH-MOON PODIATRY GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-780-8661
Mailing Address - Street 1:5610 W CERMAK RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2219
Mailing Address - Country:US
Mailing Address - Phone:708-780-8661
Mailing Address - Fax:708-780-9537
Practice Address - Street 1:5610 W CERMAK RD UNIT 2
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2219
Practice Address - Country:US
Practice Address - Phone:708-780-8661
Practice Address - Fax:708-780-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty