Healthcare Provider Details

I. General information

NPI: 1386943561
Provider Name (Legal Business Name): LASER PODIATRY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2011
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 THOMAS JOHNSON DR STE 204
FREDERICK MD
21702-4557
US

IV. Provider business mailing address

198 THOMAS JOHNSON DR SUITE 4
FREDERICK MD
21702-4398
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-9669
  • Fax: 301-695-0346
Mailing address:
  • Phone: 301-695-9669
  • Fax: 301-695-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER E MULLENDORE
Title or Position: OWNER
Credential: DPM
Phone: 301-695-9669