Basic Information
| Provider Information | |||||||||
| NPI: | 1619331931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEIDECKER | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3733 PARK EAST DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Practice Location | |||||||||
| Address1: | 3733 PARK EAST DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD.0000842 | CO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.