Healthcare Provider Details

I. General information

NPI: 1295996502
Provider Name (Legal Business Name): PORTAGE PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 W CENTRE AVE
PORTAGE MI
49024-5356
US

IV. Provider business mailing address

1508 W CENTRE AVE
PORTAGE MI
49024-5356
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-4447
  • Fax: 269-327-3120
Mailing address:
  • Phone: 269-327-4447
  • Fax: 269-327-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001113
License Number StateMI

VIII. Authorized Official

Name: DAVID A VANDERBIE
Title or Position: PHYSICAN
Credential: DPM
Phone: 269-327-4447