Healthcare Provider Details

I. General information

NPI: 1083932438
Provider Name (Legal Business Name): FOOTPRINT PODIATRY CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 SOUTHERN AVE SE SUITE 209
WASHINGTON DC
20032-4689
US

IV. Provider business mailing address

4316 18TH ST NW
WASHINGTON DC
20011-4228
US

V. Phone/Fax

Practice location:
  • Phone: 202-506-1001
  • Fax: 202-506-1008
Mailing address:
  • Phone: 202-412-9664
  • Fax: 202-525-2348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberPO1000031
License Number StateDC

VIII. Authorized Official

Name: DR. MICHANGELO DARREN SCRUGGS
Title or Position: PODIATRIST/CEO
Credential: DPM
Phone: 202-506-1001