MEDICARE: DR. MICHAEL BLAKE RUNYON DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	E1908	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E1908	OTHER	CA	CALIFORNIA STATE LICENSE

General Provider Information

NPI Number	:	1225006950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL BLAKE RUNYON DPM

Provider Business Mailing Address
First Line	:	13701 BURBANK BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-5040
Country	:	US
Telephone Number	:	818-997-1216
Fax Number	:	818-997-4458

Provider Business Practice Location Address
First Line	:	13701 BURBANK BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-5040
Country	:	US
Telephone Number	:	818-997-1216
Fax Number	:	818-997-4458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	03/07/2023

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