Provider Demographics
NPI:1033202957
Name:FOOT CENTERS OF NC, P.A.
Entity Type:Organization
Organization Name:FOOT CENTERS OF NC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:PETERY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:336-218-8490
Mailing Address - Street 1:76764 LANCELOT CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-7103
Mailing Address - Country:US
Mailing Address - Phone:760-408-5053
Mailing Address - Fax:760-345-3609
Practice Address - Street 1:3303 HEALY DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1569
Practice Address - Country:US
Practice Address - Phone:336-768-8848
Practice Address - Fax:336-768-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC297213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC690193JMedicaid
NCCK4958OtherMEDICARE PTAN RAILROAD
NC690193JMedicaid
NC2327426Medicare PIN