Provider Demographics
NPI:1740615301
Name:PRO ACTIVE PODIATRY PA
Entity Type:Organization
Organization Name:PRO ACTIVE PODIATRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PARICHART
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIKAYEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-232-2240
Mailing Address - Street 1:2504 RIDGE RD
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-2569
Mailing Address - Country:US
Mailing Address - Phone:972-232-2240
Mailing Address - Fax:972-232-2241
Practice Address - Street 1:2504 RIDGE RD
Practice Address - Street 2:SUITE 101B
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-2569
Practice Address - Country:US
Practice Address - Phone:972-232-2240
Practice Address - Fax:972-232-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty