Provider Demographics
NPI:1215236864
Name:SROA, NITIE I (DPM)
Entity type:Individual
Prefix:
First Name:NITIE
Middle Name:I
Last Name:SROA
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 1:13611 PUFF RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8802
Mailing Address - Country:US
Mailing Address - Phone:419-799-1180
Mailing Address - Fax:
Practice Address - Street 1:208 COLUMBUS ST STE 200
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526-1250
Practice Address - Country:US
Practice Address - Phone:419-799-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001153A213E00000X
IN07001153B213E00000X
GAPOD001257213E00000X, 213ES0131X
FLPO3700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3700OtherPODIATRIC FLORIDA LICENSE
GAPOD001257OtherPODIATRY LICENSE
OH36.003857OtherPODIATRIC LICENSE
IN07001153AOtherPODIATRIC LICENSE
IN07001153BOtherPODIATRIC LICENSE