Healthcare Provider Details

I. General information

NPI: 1962762344
Provider Name (Legal Business Name): TEDDY MANNING MUSSELMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2012
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 JOE KNOX AVE STE 100
MOORESVILLE NC
28117-9244
US

IV. Provider business mailing address

143 JOE KNOX AVE STE 100
MOORESVILLE NC
28117-9244
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-3595
  • Fax: 704-662-3595
Mailing address:
  • Phone: 704-662-3660
  • Fax: 704-662-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3955
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number847
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: