Provider Demographics
NPI:1770996662
Name:MUDE, PRIYANKA J (DPM)
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:J
Last Name:MUDE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8328 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4820
Mailing Address - Country:US
Mailing Address - Phone:330-494-4949
Mailing Address - Fax:330-494-4945
Practice Address - Street 1:8328 CLEVELAND AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4820
Practice Address - Country:US
Practice Address - Phone:330-494-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.110003213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0822015Medicaid