Provider Demographics
NPI:1992864490
Name:AVON LAKE PODIATRY INC
Entity Type:Organization
Organization Name:AVON LAKE PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-933-4021
Mailing Address - Street 1:32730 WALKER RD
Mailing Address - Street 2:SUITE I-3
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-4100
Mailing Address - Country:US
Mailing Address - Phone:440-933-4021
Mailing Address - Fax:440-933-7132
Practice Address - Street 1:32730 WALKER RD
Practice Address - Street 2:SUITE I-3
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-4100
Practice Address - Country:US
Practice Address - Phone:440-933-4021
Practice Address - Fax:440-933-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002416213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH480004004OtherRAILROAD MEDICARE
AV9243221Medicare PIN
OH0603440001Medicare NSC
OHT80680Medicare UPIN