Provider Demographics
NPI:1255496352
Name:RECONSTRUCTIVE FOOT & ANKLE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:RECONSTRUCTIVE FOOT & ANKLE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:260-969-1950
Mailing Address - Street 1:P.O. BOX 12754
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46866-2754
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-969-0988
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000881A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200847960Medicaid
IN200847960AMedicaid
IN200847960Medicaid
IN5887650002Medicare NSC
IN200847960AMedicaid
IN5887650001Medicare NSC