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General NPI Number Information
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NPI Number | 1336367416
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Entity Type | Organization
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Legal Business Name | SANDY RIVER PODIATRY, PA
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 114 PERHAM ST
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City | FARMINGTON
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State | ME
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Zip | 04938-1520
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Country | US
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Telephone | 207-779-1002
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Fax | 207-779-1091
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Provider Business Mailing Address
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Address Line | 114 PERHAM ST
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City | FARMINGTON
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State | ME
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Zip | 04938-1520
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Country | US
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Telephone | 207-779-1002
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Fax | 207-779-1091
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY JOHNSON
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Credential | DPM
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Telephone | 207-779-1002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | POD1034
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License Number State | ME
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