Provider Demographics
NPI:1629369996
Name:LDDL SURGICAL PODIATRY ASSOCIATES
Entity Type:Organization
Organization Name:LDDL SURGICAL PODIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-709-3405
Mailing Address - Street 1:20 VERMEER DR
Mailing Address - Street 2:APT 11
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2339
Mailing Address - Country:US
Mailing Address - Phone:732-709-3405
Mailing Address - Fax:
Practice Address - Street 1:20 VERMEER DR
Practice Address - Street 2:APT 11
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-2339
Practice Address - Country:US
Practice Address - Phone:732-709-3405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00307600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty