Healthcare Provider Details

I. General information

NPI: 1932297264
Provider Name (Legal Business Name): EASTOVER FOOT & ANKLE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 N. TRADE STREET SUITE 100
MATTHEWS NC
28105-5017
US

IV. Provider business mailing address

PO BOX 1539
MATTHEWS NC
28106-1539
US

V. Phone/Fax

Practice location:
  • Phone: 704-841-4000
  • Fax: 704-841-4338
Mailing address:
  • Phone: 704-841-4000
  • Fax: 704-841-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number200001392347
License Number StateNC

VIII. Authorized Official

Name: RONALD VICTOR FUTERMAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 704-841-4000