1548836000 NPI number — MONTOYA PODIATRY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548836000 NPI number — MONTOYA PODIATRY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTOYA PODIATRY CENTER, 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:
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:
1548836000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
806 N ROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34741-4944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-753-4452
Provider Business Mailing Address Fax Number:
407-613-2265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 N ROSE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34741-4944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-753-4452
Provider Business Practice Location Address Fax Number:
407-613-2265
Provider Enumeration Date:
06/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MONTOYA
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
908-553-5581

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111560200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: N8982 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111560200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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