Provider Demographics
NPI:1396935425
Name:UNIVERSITY FOOT CENTER INC
Entity type:Organization
Organization Name:UNIVERSITY FOOT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DPM
Authorized Official - Prefix:
Authorized Official - First Name:STEVENTON
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-488-9478
Mailing Address - Street 1:1208 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2501
Mailing Address - Country:US
Mailing Address - Phone:614-488-9478
Mailing Address - Fax:614-488-4836
Practice Address - Street 1:1208 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2501
Practice Address - Country:US
Practice Address - Phone:614-488-9478
Practice Address - Fax:614-488-4836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002797213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0412119Medicaid
OHDG3159OtherRAILROAD MEDICARE
OHDG3159OtherRAILROAD MEDICARE
OH4649320001Medicare NSC