Provider Demographics
NPI:1437301074
Name:SERGIO, ANTONIO MARIO SR (REG SHOE-MAKER MERCH)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:MARIO
Last Name:SERGIO
Suffix:SR
Gender:M
Credentials:REG SHOE-MAKER MERCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 MISHAWAKA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1426
Mailing Address - Country:US
Mailing Address - Phone:574-246-9700
Mailing Address - Fax:
Practice Address - Street 1:1508 MISHAWAKA AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1426
Practice Address - Country:US
Practice Address - Phone:574-246-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter