Provider Demographics
NPI:1568509016
Name:EASTERN PODIATRY LLC
Entity Type:Organization
Organization Name:EASTERN PODIATRY LLC
Other - Org Name:EASTERN PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-434-2023
Mailing Address - Street 1:3777 S. PECOS MCLEOD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4265
Mailing Address - Country:US
Mailing Address - Phone:702-434-2023
Mailing Address - Fax:702-434-1976
Practice Address - Street 1:3777 S. PECOS MCLEOD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4265
Practice Address - Country:US
Practice Address - Phone:702-434-2023
Practice Address - Fax:702-434-1976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0040213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVC03159OtherMRR
NV0926600001Medicare NSC
NVV31535Medicare PIN