Provider Demographics
NPI:1104000900
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 1:761 E 200TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-2504
Mailing Address - Country:US
Mailing Address - Phone:440-383-9627
Mailing Address - Fax:440-383-9629
Practice Address - Street 1:761 E 200TH ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-2504
Practice Address - Country:US
Practice Address - Phone:440-383-9627
Practice Address - Fax:440-383-9629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2008-05-12
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
OH4771320004Medicare NSC