Healthcare Provider Details

I. General information

NPI: 1609850122
Provider Name (Legal Business Name): BRAD A. LINDSTROM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E BUTLER RD SUITE A-2
MAULDIN SC
29662-2169
US

IV. Provider business mailing address

211 E BUTLER RD SUITE A-2
MAULDIN SC
29662-2169
US

V. Phone/Fax

Practice location:
  • Phone: 864-281-9171
  • Fax: 864-281-9170
Mailing address:
  • Phone: 864-281-9171
  • Fax: 864-281-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number555
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: