Provider Demographics
NPI:1588957872
Name:MT PODIATRY, LLC
Entity type:Organization
Organization Name:MT PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:TELEB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-992-2214
Mailing Address - Street 1:1021 ASYLUM AVE
Mailing Address - Street 2:APT 407
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 ASYLUM AVE
Practice Address - Street 2:APT 407
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2436
Practice Address - Country:US
Practice Address - Phone:860-992-2214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000829213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty