Basic Information
| Provider Information | |||||||||
| NPI: | 1194944728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PODIATRIC PHYSICIANS OF ARIZONA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ARIZONA INSTITUTE OF FOOTCARE PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847818 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808348804 | ||||||||
| FaxNumber: | 4804648287 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 S STAPLEY DR | ||||||||
| Address2: | 132 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852046634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808348804 | ||||||||
| FaxNumber: | 4804648287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6175627070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | CD4380 | 01 | AZ | PALMETTO GBA, RAILROAD MEDICARE | OTHER | 500144 | 05 | AZ | MEDICAID |