Healthcare Provider Details

I. General information

NPI: 1477317667
Provider Name (Legal Business Name): PNC PODIATRY OF SOUTHERN CALIFORNIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 WILSHIRE BLVD STE 101
SANTA MONICA CA
90403-5742
US

IV. Provider business mailing address

PO BOX 31502
BELFAST ME
04915-0168
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-0011
  • Fax: 310-828-2001
Mailing address:
  • Phone: 310-828-0011
  • Fax: 310-828-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

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