Healthcare Provider Details

I. General information

NPI: 1164736476
Provider Name (Legal Business Name): PARK ROW PODIATRY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 6TH AVE
SAN DIEGO CA
92101-1643
US

IV. Provider business mailing address

2306 6TH AVE
SAN DIEGO CA
92101-1643
US

V. Phone/Fax

Practice location:
  • Phone: 619-239-3286
  • Fax: 619-239-0172
Mailing address:
  • Phone: 619-239-3286
  • Fax: 619-239-0172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE2474
License Number StateCA

VIII. Authorized Official

Name: DR. NICHOLAS NELSON DESANTIS
Title or Position: CEO/OWNER
Credential: DPM
Phone: 619-239-3286