Provider Demographics
NPI:1164736476
Name:PARK ROW PODIATRY INC.
Entity Type:Organization
Organization Name:PARK ROW PODIATRY INC.
Other - Org Name:NICHOLAS N. DESANTIS DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:619-239-3286
Mailing Address - Street 1:2306 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1643
Mailing Address - Country:US
Mailing Address - Phone:619-239-3286
Mailing Address - Fax:619-239-0172
Practice Address - Street 1:2306 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1643
Practice Address - Country:US
Practice Address - Phone:619-239-3286
Practice Address - Fax:619-239-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2474213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT19202Medicare UPIN
CA6454020001Medicare NSC