Basic Information
| Provider Information | |||||||||
| NPI: | 1114101110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY PODIATRY ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALLEY PODIATRY ASSOCIATES PC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10417 | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010412017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135400150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 81 WILLIMANSETT ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HADLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010753000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135360912 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLF | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4135360289 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1786 | MA | N | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
No ID Information.