Healthcare Provider Details

I. General information

NPI: 1861928186
Provider Name (Legal Business Name): MARYLAND FOOT AND ANKLE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LIBERTY RD STE 100
ELDERSBURG MD
21784-7949
US

IV. Provider business mailing address

1010 LIBERTY RD STE 100
ELDERSBURG MD
21784-7949
US

V. Phone/Fax

Practice location:
  • Phone: 410-795-2155
  • Fax: 410-795-2154
Mailing address:
  • Phone: 410-795-2155
  • Fax: 410-795-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01503
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN LEWIS
Title or Position: OWNER
Credential: DPM
Phone: 410-795-2155