Provider Demographics
NPI:1710129549
Name:MOUNTAIN PODIATRY
Entity Type:Organization
Organization Name:MOUNTAIN PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:S
Authorized Official - Last Name:POLITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PDM
Authorized Official - Phone:702-240-8038
Mailing Address - Street 1:653 N TOWN CENTER DR STE 118
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0515
Mailing Address - Country:US
Mailing Address - Phone:702-240-8038
Mailing Address - Fax:702-240-2256
Practice Address - Street 1:653 N TOWN CENTER DR STE 118
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0515
Practice Address - Country:US
Practice Address - Phone:702-240-8038
Practice Address - Fax:702-240-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9811213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty