Provider Demographics
NPI:1083852552
Name:HOMER, VON MAURICE (BOCPD)
Entity Type:Individual
Prefix:MR
First Name:VON
Middle Name:MAURICE
Last Name:HOMER
Suffix:
Gender:M
Credentials:BOCPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MISSION WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3651
Mailing Address - Country:US
Mailing Address - Phone:302-983-9705
Mailing Address - Fax:866-443-2024
Practice Address - Street 1:17 MISSION WOOD WAY
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3651
Practice Address - Country:US
Practice Address - Phone:302-983-9705
Practice Address - Fax:866-443-2024
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC36341174400000X, 213E00000X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No174400000XOther Service ProvidersSpecialist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC36341Medicare PIN
MDC36341Medicare PIN
MAC36341Medicare PIN
FLC36341Medicare PIN