Basic Information
| Provider Information | |||||||||
| NPI: | 1780640995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEMA | ||||||||
| FirstName: | SHITAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372987351 | ||||||||
| FaxNumber: | 9372989458 | ||||||||
| Practice Location | |||||||||
| Address1: | 4441 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372987351 | ||||||||
| FaxNumber: | 9372989458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | 36003246P | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2222080 | 05 | OH | MEDICAID |