Provider Demographics
NPI:1093795320
Name:FOOT ANKLE ASSOCIATED OF THE DESERT
Entity Type:Organization
Organization Name:FOOT ANKLE ASSOCIATED OF THE DESERT
Other - Org Name:FOOT ANKLE ASSOCIATES OF THE DESERT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PODIATRY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:EBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-863-0070
Mailing Address - Street 1:82013 DR CARREON BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5832
Mailing Address - Country:US
Mailing Address - Phone:760-863-0048
Mailing Address - Fax:
Practice Address - Street 1:82013 DR CARREON BLVD
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5832
Practice Address - Country:US
Practice Address - Phone:760-863-0048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E44950Medicare UPIN