Provider Demographics
NPI:1265280275
Name:SHALL, ANDREW MICAH (DPM)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MICAH
Last Name:SHALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 OMALLEY DR APT 406
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-7511
Mailing Address - Country:US
Mailing Address - Phone:419-705-6870
Mailing Address - Fax:
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-960-3748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59.001032213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist