1326106139 NPI number — PHYSICIAN'S FOOTWEAR

Table of content: (NPI 1326106139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326106139 NPI number — PHYSICIAN'S FOOTWEAR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN'S FOOTWEAR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326106139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 THOMAS JOHNSON DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21702-4384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-696-0600
Provider Business Mailing Address Fax Number:
301-696-8872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63 THOMAS JOHNSON DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21702-4384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-696-0600
Provider Business Practice Location Address Fax Number:
303-696-8872
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-696-0600

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  10835289 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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