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Organization
LIBERTY DAYTON FOOT & ANKLE CENTER
Active
Organization
LIBERTY DAYTON FOOT & ANKLE CENTER
Active
Other names
LIBERTY DAYTON FOOT & ANKLE CENTER
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LAWRENCE S MACTAVISH D.P.M. (PHYSICIAN OWNER)
(936) 336-2633
Entity
Organization
Contact information
Practice address
1825 GRAND AVE, LIBERTY, TX 77575-4705
(936) 336-2633
(936) 336-6031
Mailing address
PO BOX 1160, LIBERTY, TX 77575-1160
(281) 444-4114
(281) 453-1269
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
506
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00J24P
BCBS
TX
05
—
121574103
—
TX
05
—
199497201
—
TX
01
—
DG6815
RR MEDICARE
TX
Enumeration date
07/01/2006
Last updated
06/19/2009
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