Provider Demographics
NPI:1114256062
Name:MARYLAND FOOT & ANKLE RESTORATION, LLC
Entity Type:Organization
Organization Name:MARYLAND FOOT & ANKLE RESTORATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNY
Authorized Official - Middle Name:JAMAL
Authorized Official - Last Name:MOTRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-519-3668
Mailing Address - Street 1:PO BOX 86284
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-6284
Mailing Address - Country:US
Mailing Address - Phone:301-519-3668
Mailing Address - Fax:301-519-7461
Practice Address - Street 1:8903 SHADY GROVE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1308
Practice Address - Country:US
Practice Address - Phone:301-519-3668
Practice Address - Fax:301-519-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01450213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6342390001Medicare NSC
MD170150Medicare PIN