Provider Demographics
NPI:1962762344
Name:MUSSELMAN, TEDDY MANNING (DPM)
Entity type:Individual
Prefix:
First Name:TEDDY
Middle Name:MANNING
Last Name:MUSSELMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 JOE KNOX AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9244
Mailing Address - Country:US
Mailing Address - Phone:704-662-3660
Mailing Address - Fax:704-662-3595
Practice Address - Street 1:143 JOE KNOX AVE STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9244
Practice Address - Country:US
Practice Address - Phone:704-662-3595
Practice Address - Fax:704-662-3595
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-20
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3955213E00000X
NC847213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty