Provider Demographics
NPI:1235845553
Name:PRESTIGE PODIATRY CARE
Entity Type:Organization
Organization Name:PRESTIGE PODIATRY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-930-7335
Mailing Address - Street 1:296 SOUND BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-1626
Mailing Address - Country:US
Mailing Address - Phone:203-563-8383
Mailing Address - Fax:
Practice Address - Street 1:296 SOUND BEACH AVE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1626
Practice Address - Country:US
Practice Address - Phone:203-563-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1295267730OtherPODIATRY