Provider Demographics
NPI:1871192716
Name:INDIANA FOOT AND ANKLE SPECIALIST LLC
Entity Type:Organization
Organization Name:INDIANA FOOT AND ANKLE SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:765-729-1083
Mailing Address - Street 1:2106 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2150
Mailing Address - Country:US
Mailing Address - Phone:765-284-3879
Mailing Address - Fax:
Practice Address - Street 1:2106 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2150
Practice Address - Country:US
Practice Address - Phone:765-284-3879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty