Provider Demographics
NPI:1003809682
Name:SOUTH LYON FOOT & ANKLE SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:SOUTH LYON FOOT & ANKLE SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROGIOCOMO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-486-8886
Mailing Address - Street 1:22245 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1639
Mailing Address - Country:US
Mailing Address - Phone:248-486-8886
Mailing Address - Fax:248-486-8887
Practice Address - Street 1:22245 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1639
Practice Address - Country:US
Practice Address - Phone:248-486-8886
Practice Address - Fax:248-486-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4856311830OtherBCBS
MI5126840001Medicare NSC
MI0N94790Medicare PIN
U67365Medicare UPIN