| Name | Value |
|---|---|
| PROVIDER TYPE | Podiatric Medicine and Surgery Service |
| CLASSIFICATION | Podiatrist |
| AREA OF SPECIALIZATION | Dermatology |
| STATUS | Inactive |
| DATE INACTIVATED | 1998-10-20 00:00:00 |
| VA CODE | V120201 |
| reserved | A, Try V1202-- |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255027 |
| EFFECTIVE DATE/TIME |
|