=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942432505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUPERTINO PODIATRY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2009
-----------------------------------------------------
Last Update Date | 08/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10353 TORRE AVE SUITE C
-----------------------------------------------------
City | CUPERTINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95014-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-446-5811
-----------------------------------------------------
Fax | 408-996-1637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15100 LOS GATOS BLVD STE 4
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-6234
-----------------------------------------------------
Fax | 408-358-3389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CMO
-----------------------------------------------------
Name | DR. ALEXANDER REYZELMAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 415-292-0638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E4260
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------