Healthcare Provider Details

I. General information

NPI: 1871192716
Provider Name (Legal Business Name): INDIANA FOOT AND ANKLE SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 W MCGALLIARD RD
MUNCIE IN
47304-2150
US

IV. Provider business mailing address

2106 W MCGALLIARD RD
MUNCIE IN
47304-2150
US

V. Phone/Fax

Practice location:
  • Phone: 765-284-3879
  • Fax:
Mailing address:
  • Phone: 765-284-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW T DEWITT
Title or Position: OWNER
Credential: DPM
Phone: 765-729-1083