MEDICARE: EASTERN PODIATRY LLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	0040	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C03159	OTHER	NV	MRR

General Provider Information

NPI Number	:	1568509016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN PODIATRY LLC

Provider Business Mailing Address
First Line	:	3777 S. PECOS MCLEOD
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4265
Country	:	US
Telephone Number	:	702-434-2023
Fax Number	:	702-434-1976

Provider Business Practice Location Address
First Line	:	3777 S. PECOS MCLEOD
Second Line	:	SUITE 103
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4265
Country	:	US
Telephone Number	:	702-434-2023
Fax Number	:	702-434-1976

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEREMY W. WOOD
Credential	:	D.P.M.
Telephone Number	:	702-434-2023

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	11/02/2010

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Directions to “EASTERN PODIATRY LLC ” Practice Location

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