Healthcare Provider Details

I. General information

NPI: 1952783920
Provider Name (Legal Business Name): MOUNTAIN PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 N TOWN CENTER DR SUITE #118
LAS VEGAS NV
89144-0514
US

IV. Provider business mailing address

653 N TOWN CENTER DR SUITE #118
LAS VEGAS NV
89144-0514
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-8038
  • Fax: 702-363-1079
Mailing address:
  • Phone: 702-240-8038
  • Fax: 702-363-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number9811
License Number StateNV

VIII. Authorized Official

Name: JODI SUE POLITZ
Title or Position: PRESIDENT
Credential: DPM
Phone: 702-240-8038