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General NPI Number Information
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NPI Number | 1275867228
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Entity Type | Organization
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Legal Business Name | BROCKTON PODIATRY GROUP A PROF CORP
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Dates
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Enumeration Date | 09/23/2009
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 16 E FERN AVE SUITE B
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City | REDLANDS
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State | CA
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Zip | 92373-4000
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Country | US
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Telephone | 909-793-2379
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Fax | 909-793-9660
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Provider Business Mailing Address
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Address Line | 16 E FERN AVE SUITE B
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City | REDLANDS
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State | CA
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Zip | 92373-4000
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Country | US
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Telephone | 909-793-2379
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Fax | 909-793-9660
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | MICHAEL N DURRANT
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Credential | DPM MPH
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Telephone | 909-793-2379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | E1514
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License Number State | CA
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