Basic Information
| Provider Information | |||||||||
| NPI: | 1619951613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGHSMITH | ||||||||
| FirstName: | DWAYNE | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | 7074545901 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 MASON ST FL 2D | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074274900 | ||||||||
| FaxNumber: | 7074545901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | E3376 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000E33760 | 05 | CA | MEDICAID |