Basic Information
Provider Information | |||||||||
NPI: | 1720427040 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MESHULAM | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | HAL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4201 WINFIELD RD | ||||||||
Address2: |   | ||||||||
City: | WARRENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605554025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3312216377 | ||||||||
FaxNumber: | 3312212357 | ||||||||
Practice Location | |||||||||
Address1: | 130 S MAIN ST STE 202 | ||||||||
Address2: |   | ||||||||
City: | LOMBARD | ||||||||
State: | IL | ||||||||
PostalCode: | 601482670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3312219004 | ||||||||
FaxNumber: | 3312212760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2013 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 07001225A | IN | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | 07001225A | IN | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 213ES0103X | 016005803 | IL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 016005803 | 05 | IL |   | MEDICAID | 508770011 | 01 |   | MEDICARE | OTHER | 07001225A | 01 |   | STATE IN | OTHER |