Healthcare Provider Details

I. General information

NPI: 1306104724
Provider Name (Legal Business Name): JOHN ROBERT TADDEO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 RIDGE RD
PARMA OH
44129-2633
US

IV. Provider business mailing address

5625 RIDGE RD
PARMA OH
44129-2633
US

V. Phone/Fax

Practice location:
  • Phone: 440-884-4100
  • Fax: 440-884-4742
Mailing address:
  • Phone: 440-884-4100
  • Fax: 440-884-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number36.003732
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003732
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: