Provider Demographics
NPI:1063894848
Name:MOBILE PODIATRY OF INDIANA
Entity type:Organization
Organization Name:MOBILE PODIATRY OF INDIANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSKY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-259-9183
Mailing Address - Street 1:12910 SHELBYVILLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2404
Mailing Address - Country:US
Mailing Address - Phone:855-259-9183
Mailing Address - Fax:502-254-4086
Practice Address - Street 1:4501 UPPER MT VERNON RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712
Practice Address - Country:US
Practice Address - Phone:855-259-9183
Practice Address - Fax:502-254-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty