Healthcare Provider Details

I. General information

NPI: 1104079250
Provider Name (Legal Business Name): JOHN ALEXANDER MACLEOD D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2008
Last Update Date: 11/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 RESERVOIR AVE
CRANSTON RI
02910-4436
US

IV. Provider business mailing address

925 RESERVOIR AVE
CRANSTON RI
02910-4436
US

V. Phone/Fax

Practice location:
  • Phone: 401-714-6997
  • Fax: 401-942-5986
Mailing address:
  • Phone: 401-714-6997
  • Fax: 401-942-5986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM00220
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDPM00220
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: