Healthcare Provider Details

I. General information

NPI: 1053392027
Provider Name (Legal Business Name): DOWNTOWN SKYWAY FOOT SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 517 MEDICAL ARTS BLDG
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

825 NICOLLET MALL SUITE 517 MEDICAL ARTS BLDG
MINNEAPOLIS MN
55402-2606
US

V. Phone/Fax

Practice location:
  • Phone: 612-332-7720
  • Fax: 612-333-8981
Mailing address:
  • Phone: 612-332-7720
  • Fax: 612-333-8981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number359
License Number StateMN

VIII. Authorized Official

Name: DR. WILLIAM BOLIN LOCKNER
Title or Position: OWNER
Credential: DPM
Phone: 612-332-7720