=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669716478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA MARIE CHWASTIAK D.P.M.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 11/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3651 LAKE CENTER DR.
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-385-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27650 SE HIGHWAY 42
-----------------------------------------------------
City | UMATILLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-241-3320
-----------------------------------------------------
Fax | 352-669-6925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | PO 3582
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | SC-004063-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------