Provider Demographics
NPI:1053648824
Name:PRESTIGE FOOT AND ANKLE PC
Entity Type:Organization
Organization Name:PRESTIGE FOOT AND ANKLE PC
Other - Org Name:PRESTIGE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:AGRICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-846-4111
Mailing Address - Street 1:6299 GUION RD STE C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-2530
Mailing Address - Country:US
Mailing Address - Phone:317-931-0664
Mailing Address - Fax:888-510-7211
Practice Address - Street 1:277 E CARMEL DR
Practice Address - Street 2:SUITE D
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2609
Practice Address - Country:US
Practice Address - Phone:317-846-4666
Practice Address - Fax:317-846-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000947A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDP9942Medicare PIN
IN264350Medicare PIN
IN6332990001Medicare NSC