Provider Demographics
NPI:1164755096
Name:MIAMI VALLEY PODIATRY ASSOCIATES LLC
Entity Type:Organization
Organization Name:MIAMI VALLEY PODIATRY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-382-2347
Mailing Address - Street 1:1435 ROMBACH AVE
Mailing Address - Street 2:UNIT 6
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-1991
Mailing Address - Country:US
Mailing Address - Phone:937-382-2347
Mailing Address - Fax:
Practice Address - Street 1:1435 ROMBACH AVE
Practice Address - Street 2:UNIT 6
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-1991
Practice Address - Country:US
Practice Address - Phone:937-382-2347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002504213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2442539Medicaid
OH9314833Medicare PIN
OH2442539Medicaid