Basic Information
| Provider Information | |||||||||
| NPI: | 1679969364 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SO | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 5055 A ST STE 400A | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685104957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0244834485 | ||||||||
| FaxNumber: | 4024835372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 376 | NE | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | POD-000905 | AZ | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 390200000X | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.