Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 555 | SC |
NPI | 1609850122 |
---|---|
Provider Name | Dr. Brad A. Lindstrom |
First Address | Mauldin, SC 29662-2169 |
Second Address | Mauldin, SC 29662-2169 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
735550 | (05) | SC |
U68869 | (02) | SC |