Basic Information
| Provider Information | |||||||||
| NPI: | 1598702847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY FOOT AND LEG CENTER PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 730 GOODLETTE RD N STE 102 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394303668 | ||||||||
| FaxNumber: | 2396929436 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 GOODLETTE RD N STE 102 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394303668 | ||||||||
| FaxNumber: | 2396929436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAM | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | KWAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2394303668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO3169 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | PO3169 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 118268 | 01 | FL | GREAT WEST | OTHER | 5523550001 | 01 | FL | NHIC REGION A | OTHER | 611311900 | 01 | FL | DEPARTMENT OF LABOR | OTHER | 65898 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | K8292 | 01 | FL | MEDICARE | OTHER | 290194 | 01 | FL | HEALTHY KIDS | OTHER | 5523550001 | 01 | FL | REGION C DMERC | OTHER |