Provider Demographics
NPI:1679673123
Name:LAIRD, ROY CLINT (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:CLINT
Last Name:LAIRD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SHAMROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1630
Mailing Address - Country:US
Mailing Address - Phone:941-493-8666
Mailing Address - Fax:941-497-5411
Practice Address - Street 1:115 SHAMROCK BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-1630
Practice Address - Country:US
Practice Address - Phone:941-493-8666
Practice Address - Fax:941-497-5411
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2934213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7600362Medicaid
U87135Medicare UPIN
FL7600362Medicaid