Provider Demographics
NPI:1730574757
Name:ACTIVE FOOT AND ANKLE OF CAROLINA PLLC
Entity type:Organization
Organization Name:ACTIVE FOOT AND ANKLE OF CAROLINA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUNJED
Authorized Official - Middle Name:S
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-547-0123
Mailing Address - Street 1:632 CEDAR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-8376
Mailing Address - Country:US
Mailing Address - Phone:757-547-0123
Mailing Address - Fax:
Practice Address - Street 1:1076 US HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7627
Practice Address - Country:US
Practice Address - Phone:252-333-3111
Practice Address - Fax:252-333-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty