Provider Demographics
NPI:1780048108
Name:MONTICELLO PODIATRY LLC
Entity type:Organization
Organization Name:MONTICELLO PODIATRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MURTUZA
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:PEERBHAI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:765-430-6963
Mailing Address - Street 1:101 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-2110
Mailing Address - Country:US
Mailing Address - Phone:844-687-3338
Mailing Address - Fax:844-687-3338
Practice Address - Street 1:101 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-2110
Practice Address - Country:US
Practice Address - Phone:844-687-3338
Practice Address - Fax:844-687-3338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTICELLO PODIATRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001110A213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty