Healthcare Provider Details

I. General information

NPI: 1649467549
Provider Name (Legal Business Name): GREAT LAKES PODIATRY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 LEAR INDUSTRIAL PKWY SUITE 1A
AVON OH
44011-1379
US

IV. Provider business mailing address

1502 LEAR INDUSTRIAL PKWY SUITE 1A
AVON OH
44011-1379
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-5400
  • Fax: 440-937-5533
Mailing address:
  • Phone: 440-937-5400
  • Fax: 440-937-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0H 3122
License Number StateOH

VIII. Authorized Official

Name: DR. KAREN MARTINKO
Title or Position: PHYSICIAN/OWNER/PRESIDENT
Credential: DPM
Phone: 440-937-5400