Provider Demographics
NPI:1184650921
Name:DISORDERS OF THE FOOT AND ANKLE
Entity Type:Organization
Organization Name:DISORDERS OF THE FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DREEBEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-488-4008
Mailing Address - Street 1:5580 LA JOLLA BLVD #55
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-488-4008
Mailing Address - Fax:877-297-2958
Practice Address - Street 1:331 SEA RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-488-4008
Practice Address - Fax:877-297-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 207XX0004X
CAG67534207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G675340Medicaid
CA200045199OtherRAILROAD MEDICARE PTAN
CAE64314Medicare UPIN
CA4260350001Medicare NSC
CAW19129Medicare PIN