1518393941 NPI number — FEETLABS SC

Table of content: RAFAEL GASPAR GONZALEZ MD (NPI 1740637438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518393941 NPI number — FEETLABS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FEETLABS SC
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:
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:
1518393941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1207 S MATTIS AVE STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61821-4862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-607-1186
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 S MATTIS AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61821-4862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-607-1186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WALTERS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
217-607-1186

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  016005102 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19321186431 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com