Provider Demographics
NPI:1194725523
Name:GREENSPAN, JACOB W (DPM)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:W
Last Name:GREENSPAN
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0220
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:350 OAK KNOLL TER
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1048
Practice Address - Country:US
Practice Address - Phone:847-562-9864
Practice Address - Fax:847-562-9865
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003364213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003364Medicaid
ILT37845Medicare UPIN
IL480023483Medicare PIN
IL016003364Medicaid
ILK10254Medicare PIN
IL209978Medicare PIN
ILK10256Medicare PIN
ILK10255Medicare PIN
IL209979Medicare PIN
IL209983Medicare PIN