Provider Demographics
NPI:1972600104
Name:PODIATRY LTD
Entity type:Organization
Organization Name:PODIATRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERBA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ALECK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-399-5621
Mailing Address - Street 1:3511 WESTERN BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3133
Mailing Address - Country:US
Mailing Address - Phone:757-399-5621
Mailing Address - Fax:757-397-5889
Practice Address - Street 1:3511 WESTERN BRANCH BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3133
Practice Address - Country:US
Practice Address - Phone:757-399-5621
Practice Address - Fax:757-397-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009332146Medicaid
VA0545880001Medicare NSC
VA009332146Medicaid