Provider Demographics
NPI:1689603805
Name:LIBERTY DAYTON FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:LIBERTY DAYTON FOOT & ANKLE CENTER
Other - Org Name:LIBERTY DAYTON FOOT & ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MACTAVISH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:936-336-2633
Mailing Address - Street 1:PO BOX 1160
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-1160
Mailing Address - Country:US
Mailing Address - Phone:281-444-4114
Mailing Address - Fax:281-453-1269
Practice Address - Street 1:1825 GRAND AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-4705
Practice Address - Country:US
Practice Address - Phone:936-336-2633
Practice Address - Fax:936-336-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX506213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDG6815OtherRR MEDICARE
TX00J24POtherBCBS
TX121574103Medicaid
TX199497201Medicaid
TX0660130002Medicare NSC
TX00J24PMedicare PIN
TX8K5256Medicare PIN
TX121574103Medicaid