Healthcare Provider Details

I. General information

NPI: 1114942158
Provider Name (Legal Business Name): TERRE HAUTE PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 S 4TH ST
TERRE HAUTE IN
47802
US

IV. Provider business mailing address

3760 S 4TH ST
TERRE HAUTE IN
47802
US

V. Phone/Fax

Practice location:
  • Phone: 812-234-3558
  • Fax: 812-232-0355
Mailing address:
  • Phone: 812-234-3558
  • Fax: 812-232-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number07000448
License Number StateIN

VIII. Authorized Official

Name: DR. ELLIOT L KLEINMAN
Title or Position: PHYSICIAN/OWNER
Credential: DPM
Phone: 812-234-3558