Provider Demographics
NPI:1700076403
Name:DYNAMIC FOOT CARE LLC
Entity Type:Organization
Organization Name:DYNAMIC FOOT CARE LLC
Other - Org Name:DYNAMIC FOOT CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-869-0669
Mailing Address - Street 1:585 WHITE POND DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1115
Mailing Address - Country:US
Mailing Address - Phone:330-869-0669
Mailing Address - Fax:330-869-5769
Practice Address - Street 1:585 WHITE POND DR
Practice Address - Street 2:SUITE E
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1115
Practice Address - Country:US
Practice Address - Phone:330-869-0669
Practice Address - Fax:330-869-5769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-29
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003438213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2769526Medicaid
OHDY9370371Medicare PIN
OH2769526Medicaid