Provider Demographics
NPI:1629699798
Name:MODERN PODIATRY, LLC
Entity Type:Organization
Organization Name:MODERN PODIATRY, LLC
Other - Org Name:MODERN PODIATRY: FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WOOJUNG
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-645-7654
Mailing Address - Street 1:5729 LEBANON RD STE 144328
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-7260
Mailing Address - Country:US
Mailing Address - Phone:972-645-7654
Mailing Address - Fax:
Practice Address - Street 1:255 W LEBANON STE 202
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75036-3411
Practice Address - Country:US
Practice Address - Phone:972-645-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty