Healthcare Provider Details

I. General information

NPI: 1508510447
Provider Name (Legal Business Name): MONTICELLO PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1281 WIN HENTSCHEL BLVD STE 1579
WEST LAFAYETTE IN
47906-4357
US

IV. Provider business mailing address

1281 WIN HENTSCHEL BLVD STE 1579
WEST LAFAYETTE IN
47906-4357
US

V. Phone/Fax

Practice location:
  • Phone: 765-430-6963
  • Fax:
Mailing address:
  • Phone: 765-430-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MURTUZA A. PEERBHAI
Title or Position: SOLE MEMBER
Credential: DPM
Phone: 765-430-6963