Provider Demographics
NPI:1730614124
Name:PODKOWIROW, NICHOLAS ALEKSEI (DPM)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEKSEI
Last Name:PODKOWIROW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 W IL ROUTE 22 STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3419
Mailing Address - Country:US
Mailing Address - Phone:847-540-0234
Mailing Address - Fax:847-540-0867
Practice Address - Street 1:950 W IL ROUTE 22 STE 105
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3419
Practice Address - Country:US
Practice Address - Phone:847-540-0234
Practice Address - Fax:847-540-0867
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005829213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist