Healthcare Provider Details

I. General information

NPI: 1073584686
Provider Name (Legal Business Name): JAMES EDWIN PROMMERSBERGER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 WINDHAM CT SUITE #3
BOARDMAN OH
44512-5060
US

IV. Provider business mailing address

940 WINDHAM CT SUITE #3
BOARDMAN OH
44512-5060
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3348
  • Fax: 330-726-3856
Mailing address:
  • Phone: 330-726-3348
  • Fax: 330-726-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-00-2619
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36-00-2619
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: