Provider Demographics
NPI:1245239631
Name:NISHON, LARRY R (DPM)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:R
Last Name:NISHON
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 1:2158 COMMONS PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3986
Mailing Address - Country:US
Mailing Address - Phone:517-349-6855
Mailing Address - Fax:517-349-7158
Practice Address - Street 1:2158 COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3986
Practice Address - Country:US
Practice Address - Phone:517-349-6855
Practice Address - Fax:517-349-7158
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILN001085213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Not Answered213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710897Medicaid
MI4814430001OtherDMERC
MI2700008OtherPHP
MI4814430002OtherDMERC
MIT34330Medicare UPIN
MI2700008OtherPHP