Provider Demographics
NPI:1073793154
Name:ATTA J ASEF DPM LTD
Entity Type:Organization
Organization Name:ATTA J ASEF DPM LTD
Other - Org Name:LAKE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASEF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-953-1003
Mailing Address - Street 1:36001 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4643
Mailing Address - Country:US
Mailing Address - Phone:440-953-1003
Mailing Address - Fax:440-953-3556
Practice Address - Street 1:35010 CHARDON RD
Practice Address - Street 2:101A
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9010
Practice Address - Country:US
Practice Address - Phone:440-953-1003
Practice Address - Fax:440-953-3556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002887A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2085023Medicaid
OH3025514Medicaid
OH9329743Medicare PIN
OH9329741Medicare PIN
OH2085023Medicaid
OH3025514Medicaid
OH4771320004Medicare NSC