Healthcare Provider Details

I. General information

NPI: 1942432505
Provider Name (Legal Business Name): CUPERTINO PODIATRY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10353 TORRE AVE SUITE C
CUPERTINO CA
95014-3217
US

IV. Provider business mailing address

15100 LOS GATOS BLVD STE 4
LOS GATOS CA
95032-2028
US

V. Phone/Fax

Practice location:
  • Phone: 408-446-5811
  • Fax: 408-996-1637
Mailing address:
  • Phone: 408-358-6234
  • Fax: 408-358-3389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4260
License Number StateCA

VIII. Authorized Official

Name: DR. ALEXANDER REYZELMAN
Title or Position: CMO
Credential: DPM
Phone: 415-292-0638