Provider Demographics
NPI:1043245525
Name:SANTA MONICA PODIATRY GROUP, INC.
Entity Type:Organization
Organization Name:SANTA MONICA PODIATRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:BOYKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-451-1618
Mailing Address - Street 1:1260 15TH ST
Mailing Address - Street 2:SUITE 1014
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1135
Mailing Address - Country:US
Mailing Address - Phone:310-451-1618
Mailing Address - Fax:
Practice Address - Street 1:1260 15TH ST
Practice Address - Street 2:SUITE 1014
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1135
Practice Address - Country:US
Practice Address - Phone:310-451-1618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2764213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA048OtherNEIC SPECIALTY CODE
CA048OtherNEIC SPECIALTY CODE
CAWE6504Medicare PIN
CA0207250001Medicare NSC