Healthcare Provider Details

I. General information

NPI: 1336367416
Provider Name (Legal Business Name): SANDY RIVER PODIATRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PERHAM ST
FARMINGTON ME
04938-1520
US

IV. Provider business mailing address

114 PERHAM ST
FARMINGTON ME
04938-1520
US

V. Phone/Fax

Practice location:
  • Phone: 207-779-1002
  • Fax: 207-779-1091
Mailing address:
  • Phone: 207-779-1002
  • Fax: 207-779-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD1034
License Number StateME

VIII. Authorized Official

Name: DR. JEFFREY JOHNSON
Title or Position: OWNER
Credential: DPM
Phone: 207-779-1002