Healthcare Provider Details

I. General information

NPI: 1922078765
Provider Name (Legal Business Name): ELIZABETH L MASSIMINI DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N PROVIDENCE RD
MEDIA PA
19063-2101
US

IV. Provider business mailing address

1008 N PROVIDENCE RD
MEDIA PA
19063-2101
US

V. Phone/Fax

Practice location:
  • Phone: 610-892-8090
  • Fax: 610-892-8040
Mailing address:
  • Phone: 610-892-8090
  • Fax: 610-892-8040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberSC003395L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: