Provider Demographics
NPI:1245590017
Name:LAKE COUNTRY FOOT & ANKLE SC
Entity Type:Organization
Organization Name:LAKE COUNTRY FOOT & ANKLE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-695-6440
Mailing Address - Street 1:1177 QUAIL CT STE 103
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3768
Mailing Address - Country:US
Mailing Address - Phone:262-695-6440
Mailing Address - Fax:262-695-2668
Practice Address - Street 1:1177 QUAIL CT STE 103
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3768
Practice Address - Country:US
Practice Address - Phone:262-695-6440
Practice Address - Fax:262-695-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI794-025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000082018OtherP10