Provider Demographics
NPI:1700830403
Name:CHOUDHARY, SUBODH KUMAR (DPM)
Entity Type:Individual
Prefix:DR
First Name:SUBODH
Middle Name:KUMAR
Last Name:CHOUDHARY
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 1:11 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4015
Mailing Address - Country:US
Mailing Address - Phone:864-232-3668
Mailing Address - Fax:864-271-0526
Practice Address - Street 1:11 MILLS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4015
Practice Address - Country:US
Practice Address - Phone:864-232-3668
Practice Address - Fax:864-271-0526
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC107213ES0103X, 213E00000X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9955Medicaid
SC1700830403OtherNPI
T93007Medicare UPIN
SCD593Medicare PIN