=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104941400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL FOOT & ANKLE CENTERS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2270 JOLLY OAK RD SUITE 1
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-853-8951
-----------------------------------------------------
Fax | 517-913-5996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2843 E GRAND RIVER AVE #235
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-853-8951
-----------------------------------------------------
Fax | 517-913-5996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH VINCENT GONZALEZ
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 517-853-8951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | JG002023
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------