Healthcare Provider Details

I. General information

NPI: 1386185650
Provider Name (Legal Business Name): ARTISAN FOOT AND ANKLE PODIATRIC SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date: 05/16/2019
Reactivation Date: 05/22/2019

III. Provider practice location address

23141 MOULTON PKWY STE 109
LAGUNA HILLS CA
92653-1241
US

IV. Provider business mailing address

PO BOX 31502
BELFAST ME
04915-0168
US

V. Phone/Fax

Practice location:
  • Phone: 949-272-0007
  • Fax: 949-272-0006
Mailing address:
  • Phone: 415-645-4525
  • Fax: 510-399-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DEVON GLAZER
Title or Position: OWNER
Credential: DPM
Phone: 949-272-0007