1083932438 NPI number — FOOTPRINT PODIATRY CONSULTANTS, LLC

Table of content: (NPI 1083932438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083932438 NPI number — FOOTPRINT PODIATRY CONSULTANTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTPRINT PODIATRY CONSULTANTS, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1083932438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4316 18TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20011-4228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-412-9664
Provider Business Mailing Address Fax Number:
202-525-2348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1328 SOUTHERN AVE SE
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20032-4689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-506-1001
Provider Business Practice Location Address Fax Number:
202-506-1008
Provider Enumeration Date:
05/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SCRUGGS
Authorized Official First Name:
MICHANGELO
Authorized Official Middle Name:
DARREN
Authorized Official Title or Position:
PODIATRIST/CEO
Authorized Official Telephone Number:
202-506-1001

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  PO1000031 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 306106 . This is a "UNISON" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 947AMD-MD . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 0000289842002 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 050785700 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: J892 . This is a "CAREFIRST BC/BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 31290 . This is a "DC CHARTERED HEALTH" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com