Healthcare Provider Details

I. General information

NPI: 1295249902
Provider Name (Legal Business Name): SAN DIEGO FOOT & ANKLE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 CAMINO DEL RIO N STE 101
SAN DIEGO CA
92108-1630
US

IV. Provider business mailing address

2650 CAMINO DEL RIO N STE 101
SAN DIEGO CA
92108-1630
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-0777
  • Fax: 619-291-3231
Mailing address:
  • Phone: 619-291-0777
  • Fax: 619-291-3231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BENJAMIN CULLEN
Title or Position: SECRETARY
Credential: DPM
Phone: 619-291-0777