| Name | Value |
|---|---|
| PROVIDER TYPE | Podiatric Medicine & Surgery Service Providers |
| CLASSIFICATION | Podiatrist |
| AREA OF SPECIALIZATION | General Practice |
| STATUS | Inactive |
| DATE INACTIVATED | 2009-04-22 00:00:00 |
| VA CODE | V120206 |
| X12 CODE | 213EG0000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255003 |
| EFFECTIVE DATE/TIME |
|