Provider Demographics
NPI:1275867228
Name:BROCKTON PODIATRY GROUP A PROF CORP
Entity Type:Organization
Organization Name:BROCKTON PODIATRY GROUP A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:DURRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM MPH
Authorized Official - Phone:909-793-2379
Mailing Address - Street 1:16 E FERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4000
Mailing Address - Country:US
Mailing Address - Phone:909-793-2379
Mailing Address - Fax:909-793-9660
Practice Address - Street 1:16 E FERN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4000
Practice Address - Country:US
Practice Address - Phone:909-793-2379
Practice Address - Fax:909-793-9660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1514213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6491680001Medicare NSC