MEDICARE: LAFAYETTE FOOT AND ANKLE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist	07000728	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00128864	OTHER		RR MCR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003099441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAFAYETTE FOOT AND ANKLE CLINIC

Provider Business Mailing Address
First Line	:	2700 LAFAYETTE ST STE 230
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-458-9953
Fax Number	:	260-458-9238

Provider Business Practice Location Address
First Line	:	2700 LAFAYETTE ST STE 230
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-458-9953
Fax Number	:	260-458-9238

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BENNY FAIR JR.
Credential	:	DPM
Telephone Number	:	260-458-9953

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	01/06/2025

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