Healthcare Provider Details

I. General information

NPI: 1114928074
Provider Name (Legal Business Name): MICHAEL JOSPEH ACKLEY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/13/2006

III. Provider practice location address

714 S MAIN ST
CHESHIRE CT
06410-3448
US

IV. Provider business mailing address

714 S MAIN ST
CHESHIRE CT
06410-3448
US

V. Phone/Fax

Practice location:
  • Phone: 203-271-0556
  • Fax: 203-250-9951
Mailing address:
  • Phone: 203-271-0556
  • Fax: 203-250-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number395
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number395
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number395
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number395
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: