Healthcare Provider Details

I. General information

NPI: 1689682734
Provider Name (Legal Business Name): JEFFREY LEE IDOL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CHARLES STREET
LAPLATA MD
20646
US

IV. Provider business mailing address

PO BOX 59714
POTOMAC MD
20859-9714
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-3345
  • Fax: 301-934-3345
Mailing address:
  • Phone: 301-934-3345
  • Fax: 301-934-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00992
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: