Healthcare Provider Details

I. General information

NPI: 1700374667
Provider Name (Legal Business Name): ELITE PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 N 41ST CT
HOLLYWOOD FL
33021-1940
US

IV. Provider business mailing address

3381 N 41ST CT
HOLLYWOOD FL
33021-1940
US

V. Phone/Fax

Practice location:
  • Phone: 818-317-4127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: ELLIOT FIALKOFF
Title or Position: CEO
Credential:
Phone: 818-317-4127