Healthcare Provider Details

I. General information

NPI: 1164608394
Provider Name (Legal Business Name): JOSEPH ADDIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

IV. Provider business mailing address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3668
  • Fax:
Mailing address:
  • Phone: 818-242-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4289
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEPH ADDIEGO
Title or Position: OWNER
Credential: DMP
Phone: 818-242-3668