Provider Demographics
NPI:1083674378
Name:CHRISTENSEN, VERN M (DPM)
Entity Type:Individual
Prefix:
First Name:VERN
Middle Name:M
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 EARL FRYE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5519
Mailing Address - Country:US
Mailing Address - Phone:662-257-2357
Mailing Address - Fax:662-257-2399
Practice Address - Street 1:1107 EARL FRYE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5519
Practice Address - Country:US
Practice Address - Phone:662-257-2357
Practice Address - Fax:662-257-2399
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80149213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480035262OtherRR GROUP PROVIDER #
MS0119847Medicaid
MI480000134Medicare PIN
MSU68146Medicare UPIN
MI480035262OtherRR GROUP PROVIDER #