| Name | Value |
|---|---|
| PROVIDER TYPE | Podiatric Medicine & Surgery Service Providers |
| CLASSIFICATION | Podiatrist |
| AREA OF SPECIALIZATION | Sports Medicine |
| STATUS | Active |
| VA CODE | V120212 |
| X12 CODE | 213ES0000X |
| SPECIALTY CODE | 48 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255015 |
| EFFECTIVE DATE/TIME |
|