=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215041215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUMBERLAND FOOT AND ANKLE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E MAIN ST STE B
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-293-1880
-----------------------------------------------------
Fax | 856-293-1889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 E MAIN ST STE B
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-293-1880
-----------------------------------------------------
Fax | 856-293-1889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. DAVID LANING JESPERSEN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 856-293-1880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 25MD00256400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------