Healthcare Provider Details

I. General information

NPI: 1184886111
Provider Name (Legal Business Name): MICHAEL P MASKILL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 10/23/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7971 MOORSBRIDGE RD
PORTAGE MI
49024-4075
US

IV. Provider business mailing address

7971 MOORSBRIDGE RD
PORTAGE MI
49024-4075
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-2094
  • Fax:
Mailing address:
  • Phone: 269-323-2094
  • Fax: 269-323-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002313
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD1063
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: