Healthcare Provider Details

I. General information

NPI: 1770996662
Provider Name (Legal Business Name): PRIYANKA J MUDE D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 12/06/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8328 CLEVELAND AVE NW
NORTH CANTON OH
44720-4820
US

IV. Provider business mailing address

8328 CLEVELAND AVE NW
NORTH CANTON OH
44720-4820
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-4949
  • Fax:
Mailing address:
  • Phone: 330-494-4949
  • Fax: 330-494-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36.110003
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: