Provider Demographics
NPI:1023013653
Name:PODIATRY CENTER, PSC
Entity Type:Organization
Organization Name:PODIATRY CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-724-0871
Mailing Address - Street 1:PO BOX 19657
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-1657
Mailing Address - Country:US
Mailing Address - Phone:787-724-0871
Mailing Address - Fax:787-724-0886
Practice Address - Street 1:1413 AVE FERNANDEZ JUNCOS
Practice Address - Street 2:STOP 20
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00909-2649
Practice Address - Country:US
Practice Address - Phone:787-724-0871
Practice Address - Fax:787-724-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0039213ES0131X
PR1302060001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRT 50886Medicare UPIN
PR1302060001Medicare NSC
PR071840Medicare ID - Type Unspecified