MEDICARE: SAN BERNARDINO FOOT CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	E4416	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CI863B	OTHER	CA	MEDICARE PTAN
3	DD297Z	OTHER	CA	MEDICARE INDIVIDUAL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154352037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN BERNARDINO FOOT CLINIC, INC.

Provider Business Mailing Address
First Line	:	2095 N WATERMAN AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4834
Country	:	US
Telephone Number	:	909-882-3800
Fax Number	:	909-882-3380

Provider Business Practice Location Address
First Line	:	2095 N WATERMAN AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4834
Country	:	US
Telephone Number	:	909-882-3800
Fax Number	:	909-882-3380

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MARIA CUEVAS
Credential	:
Telephone Number	:	909-882-3800

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	02/21/2024

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Directions to “SAN BERNARDINO FOOT CLINIC, INC. ” Practice Location

Language	Start Address	Practice Location

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