Basic Information
Provider Information | |||||||||
NPI: | 1083670947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARTRIDGE | ||||||||
FirstName: | CARMEN | ||||||||
MiddleName: | O. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUCIANO | ||||||||
OtherFirstName: | CARMEN | ||||||||
OtherMiddleName: | O. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6101 BLUE LAGOON DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331263168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055002000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1979 W HILLSBORO BLVD STE 1 | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334421444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544284800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2006 | ||||||||
LastUpdateDate: | 09/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | PO-2600 | FL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
ID | Type | State | Issuer | Description | 390330300 | 05 | FL |   | MEDICAID |