1700015849 NPI number — CORY HAIMON DPM PA

Table of content: (NPI 1700015849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700015849 NPI number — CORY HAIMON DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORY HAIMON DPM PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GOLD COAST PODIATRY GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700015849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7431 W ATLANTIC AVE STE 33
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33446-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-496-6900
Provider Business Mailing Address Fax Number:
561-496-5348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
941 SE 1ST ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BELLE GLADE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33430-4353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-993-3668
Provider Business Practice Location Address Fax Number:
561-993-3668
Provider Enumeration Date:
07/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSON
Authorized Official First Name:
IRA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
561-993-3668

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PO0001689 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: PO0001592 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 390417200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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