Provider Demographics
NPI:1033415799
Name:FOOT AND ANKLE CLINIC, PC
Entity Type:Organization
Organization Name:FOOT AND ANKLE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHAM
Authorized Official - Middle Name:VAY
Authorized Official - Last Name:UNG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:712-255-0502
Mailing Address - Street 1:1502 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1246
Mailing Address - Country:US
Mailing Address - Phone:712-255-0502
Mailing Address - Fax:712-258-9977
Practice Address - Street 1:315 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070-2002
Practice Address - Country:US
Practice Address - Phone:605-326-5161
Practice Address - Fax:605-326-5734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00505213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD123OtherLICENSE NUMBER
SD6800454Medicaid
SD123OtherLICENSE NUMBER
SD6800454Medicaid
SDS40586Medicare PIN