Healthcare Provider Details

I. General information

NPI: 1558559278
Provider Name (Legal Business Name): GREAT LAKES PODIATRY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 WISTERIA WAY
AVON OH
44011-2614
US

IV. Provider business mailing address

4642 OBERLIN AVE SUITE 103
LORAIN OH
44053-3164
US

V. Phone/Fax

Practice location:
  • Phone: 440-282-4355
  • Fax: 440-282-4355
Mailing address:
  • Phone: 440-282-4355
  • Fax: 440-282-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number3122
License Number StateOH

VIII. Authorized Official

Name: DR. KAREN MARTINKO
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 440-282-4355