Provider Demographics
NPI:1083932438
Name:FOOTPRINT PODIATRY CONSULTANTS, LLC
Entity Type:Organization
Organization Name:FOOTPRINT PODIATRY CONSULTANTS, LLC
Other - Org Name:FOOTPRINT PODIATRY CONSULTANTS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PODIATRIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHANGELO
Authorized Official - Middle Name:DARREN
Authorized Official - Last Name:SCRUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:202-506-1001
Mailing Address - Street 1:4316 18TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4228
Mailing Address - Country:US
Mailing Address - Phone:202-412-9664
Mailing Address - Fax:202-525-2348
Practice Address - Street 1:1328 SOUTHERN AVE SE
Practice Address - Street 2:SUITE 209
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4689
Practice Address - Country:US
Practice Address - Phone:202-506-1001
Practice Address - Fax:202-506-1008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOTPRINT PODIATRY CONSULTANTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-10
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPO1000031261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC306106OtherUNISON
DC947AMD-MDOtherCAREFIRST BC/BS
DC0000289842002OtherUNITED HEALTHCARE
DC050785700Medicaid
DCJ892OtherCAREFIRST BC/BS
DC31290OtherDC CHARTERED HEALTH
U96803Medicare UPIN
DC491626Medicare PIN