MEDICARE: LIFESTYLE PODIATRY, PC

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	213ES0131X	Foot Surgery Podiatrist	N004044	NY

General Provider Information

NPI Number	:	1477743698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE PODIATRY, PC

Provider Business Mailing Address
First Line	:	1466 BLUFF CT
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-3650
Country	:	US
Telephone Number	:	770-349-9861
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 W 45TH ST
Second Line	:	SUITE 300
City	:	NEW YORK
State	:	NY
Zip	:	10036-4212
Country	:	US
Telephone Number	:	770-349-9861
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MAITRAYA D THAKER
Credential	:	DPM
Telephone Number	:	770-349-9861

Provider Enumeration Date	:	07/25/2007
Last Update Date	:	12/26/2012

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