Healthcare Provider Details

I. General information

NPI: 1033109327
Provider Name (Legal Business Name): PAUL BENJAMIN SCHODOWSKI D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 AMERICAN WAY SUITE 115
KINGSPORT TN
37660-4673
US

IV. Provider business mailing address

2004 AMERICAN WAY STE 115
KINGSPORT TN
37660-4673
US

V. Phone/Fax

Practice location:
  • Phone: 423-246-8840
  • Fax: 423-246-8559
Mailing address:
  • Phone: 423-246-8840
  • Fax: 423-246-8559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberDPM0000000479
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: