Provider Demographics
NPI:1750305306
Name:CHESAPEAKE FOOT AND ANKLE CENTER, P.A.
Entity Type:Organization
Organization Name:CHESAPEAKE FOOT AND ANKLE CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-761-0118
Mailing Address - Street 1:8030B RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1084
Mailing Address - Country:US
Mailing Address - Phone:410-761-0118
Mailing Address - Fax:410-761-5118
Practice Address - Street 1:8030B RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1084
Practice Address - Country:US
Practice Address - Phone:410-761-0118
Practice Address - Fax:410-761-5118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
MD332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD437198400Medicaid
MD4678050001Medicare NSC