Provider Demographics
NPI:1740391499
Name:FOOT DOC LLC
Entity Type:Organization
Organization Name:FOOT DOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-241-9565
Mailing Address - Street 1:2346 S LYNHURST DR
Mailing Address - Street 2:SUITE 707
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-8621
Mailing Address - Country:US
Mailing Address - Phone:317-241-9565
Mailing Address - Fax:317-241-0100
Practice Address - Street 1:2346 S LYNHURST DR
Practice Address - Street 2:SUITE 707
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-8621
Practice Address - Country:US
Practice Address - Phone:317-241-9565
Practice Address - Fax:317-241-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000969A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU98948Medicare UPIN