Provider Demographics
NPI:1902972607
Name:DR MARK A GOTFRYD PC
Entity Type:Organization
Organization Name:DR MARK A GOTFRYD PC
Other - Org Name:MARK A GOTFRYD DPM PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTFRYD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:205-853-7878
Mailing Address - Street 1:1703 CENTER POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215-5505
Mailing Address - Country:US
Mailing Address - Phone:205-853-7878
Mailing Address - Fax:205-853-8272
Practice Address - Street 1:1703 CENTER POINT PKWY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35215-5505
Practice Address - Country:US
Practice Address - Phone:205-853-7878
Practice Address - Fax:205-853-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00109213E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000071144Medicare PIN
AL000072959Medicare PIN
AL5151450001Medicare NSC