Provider Demographics
NPI:1689666539
Name:JUCHHEIM, ALWIN MAX III (DPM)
Entity Type:Individual
Prefix:
First Name:ALWIN
Middle Name:MAX
Last Name:JUCHHEIM
Suffix:III
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 1:1300 SUNSET DR
Mailing Address - Street 2:SUITE P
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4086
Mailing Address - Country:US
Mailing Address - Phone:662-226-3333
Mailing Address - Fax:662-226-7722
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE P
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-226-3333
Practice Address - Fax:662-226-7722
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80068213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011116Medicaid
MS480000004Medicare ID - Type Unspecified
MS0767580001Medicare NSC
MST20983Medicare UPIN