Provider Demographics
NPI:1326106139
Name:PHYSICIAN'S FOOTWEAR
Entity Type:Organization
Organization Name:PHYSICIAN'S FOOTWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, CPED
Authorized Official - Phone:301-696-0600
Mailing Address - Street 1:63 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4384
Mailing Address - Country:US
Mailing Address - Phone:301-696-0600
Mailing Address - Fax:301-696-8872
Practice Address - Street 1:63 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE C
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4384
Practice Address - Country:US
Practice Address - Phone:301-696-0600
Practice Address - Fax:303-696-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10835289332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4648290001Medicare ID - Type Unspecified