Provider Demographics
NPI:1588243984
Name:FERRYANTO, ERSTA PUTRA (DPM)
Entity type:Individual
Prefix:
First Name:ERSTA
Middle Name:PUTRA
Last Name:FERRYANTO
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 1:4805 N CLAREMONT AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3791
Mailing Address - Country:US
Mailing Address - Phone:678-549-6468
Mailing Address - Fax:
Practice Address - Street 1:4805 N CLAREMONT AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3791
Practice Address - Country:US
Practice Address - Phone:678-549-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016006049213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty