Healthcare Provider Details

I. General information

NPI: 1174026454
Provider Name (Legal Business Name): EAST ALABAMA PODIATRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 SKYWAY DR STE 802
OPELIKA AL
36801-7141
US

IV. Provider business mailing address

PO BOX 597
CLEMMONS NC
27012-0597
US

V. Phone/Fax

Practice location:
  • Phone: 404-538-7019
  • Fax:
Mailing address:
  • Phone: 336-306-9755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberBL001588012018
License Number StateAL

VIII. Authorized Official

Name: KETAN C DALSANIA
Title or Position: OWNER
Credential: DPM
Phone: 404-538-7019