Provider Demographics
NPI:1881724227
Name:MECKLENBURG FOOT & ANKLE ASSOCIATES AND DIABETIC FOOT CLINIC PC
Entity type:Organization
Organization Name:MECKLENBURG FOOT & ANKLE ASSOCIATES AND DIABETIC FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:LIESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-442-8433
Mailing Address - Street 1:2115 E 7TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3300
Mailing Address - Country:US
Mailing Address - Phone:704-442-8433
Mailing Address - Fax:704-817-9957
Practice Address - Street 1:2115 E 7TH ST STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3300
Practice Address - Country:US
Practice Address - Phone:704-442-8433
Practice Address - Fax:704-817-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 207XX0004X
NC356213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890268LMedicaid
NC0268LOtherGROUP NUMBER
NC890268LMedicaid
NC0268LOtherGROUP NUMBER
1202020001Medicare NSC
NC2335786Medicare PIN