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General NPI Number Information
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NPI Number | 1477743698
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Entity Type | Organization
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Legal Business Name | LIFESTYLE PODIATRY, PC
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Dates
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Enumeration Date | 07/25/2007
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Last Update Date | 12/26/2012
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Provider Practice Location Address
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Address Line | 2 W 45TH ST SUITE 300
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City | NEW YORK
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State | NY
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Zip | 10036-4212
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Country | US
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Telephone | 770-349-9861
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Fax |
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Provider Business Mailing Address
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Address Line | 1466 BLUFF CT
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City | SUWANEE
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State | GA
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Zip | 30024-3650
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Country | US
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Telephone | 770-349-9861
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MAITRAYA D THAKER
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Credential | DPM
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Telephone | 770-349-9861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | N004044
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License Number State | NY
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