Provider Demographics
NPI:1245216738
Name:PLS PODIATRY GROUP
Entity Type:Organization
Organization Name:PLS PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:AYODELE
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-836-2475
Mailing Address - Street 1:2661 E FLORENCE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4793
Mailing Address - Country:US
Mailing Address - Phone:323-583-4440
Mailing Address - Fax:
Practice Address - Street 1:2661 E FLORENCE AVE
Practice Address - Street 2:STE B
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255
Practice Address - Country:US
Practice Address - Phone:323-583-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE41591213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18321Medicare ID - Type Unspecified