Healthcare Provider Details

I. General information

NPI: 1801117684
Provider Name (Legal Business Name): BRIAN SHENG TING DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 35TH AVENUE PL SUITE 102
MOLINE IL
61265-8026
US

IV. Provider business mailing address

840 35TH AVENUE PL STE 102
MOLINE IL
61265-8026
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-5200
  • Fax: 309-762-5636
Mailing address:
  • Phone: 309-762-5655
  • Fax: 309-762-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-005485
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: