Provider Demographics
NPI:1699975375
Name:VALDOSTA FOOT & ANKLE CLINIC, P.C.
Entity type:Organization
Organization Name:VALDOSTA FOOT & ANKLE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:229-244-1211
Mailing Address - Street 1:2800 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1716
Mailing Address - Country:US
Mailing Address - Phone:229-244-1211
Mailing Address - Fax:229-244-2721
Practice Address - Street 1:2800 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1716
Practice Address - Country:US
Practice Address - Phone:229-244-1211
Practice Address - Fax:229-244-2721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty