Provider Demographics
NPI:1962596031
Name:LARGO FOOT & ANKLE HEALTH CENTER AND AMBULATORY SURGICAL CENTER,INC'
Entity type:Organization
Organization Name:LARGO FOOT & ANKLE HEALTH CENTER AND AMBULATORY SURGICAL CENTER,INC'
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEMUYIWA
Authorized Official - Middle Name:ADEKOLA
Authorized Official - Last Name:ADETUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-386-5453
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-0265
Mailing Address - Country:US
Mailing Address - Phone:301-386-5453
Mailing Address - Fax:301-386-5396
Practice Address - Street 1:1450 MERCANTILE LN STE 151
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5386
Practice Address - Country:US
Practice Address - Phone:301-386-5453
Practice Address - Fax:301-386-5396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01264213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035063500Medicaid
MD319906101Medicaid
MD4038530001Medicare NSC
DC035063500Medicaid
MD210NMedicare PIN