Provider Demographics
NPI:1073510244
Name:BROADWAY FOOT CLINIC CORPORATION
Entity Type:Organization
Organization Name:BROADWAY FOOT CLINIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SONNY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OJIKUTU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-884-7880
Mailing Address - Street 1:3290 GRANT ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1015
Mailing Address - Country:US
Mailing Address - Phone:219-884-7880
Mailing Address - Fax:219-884-7880
Practice Address - Street 1:3290 GRANT ST
Practice Address - Street 2:SUITE 108
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1015
Practice Address - Country:US
Practice Address - Phone:219-884-7880
Practice Address - Fax:219-884-7880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000445A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10058560Medicaid
IN10058560Medicaid
INT81893Medicare UPIN