Provider Demographics
NPI:1295813491
Name:FOOT & ANKLE INSTITUTE OF THE WEST A PODIATRY CORPORATION
Entity Type:Organization
Organization Name:FOOT & ANKLE INSTITUTE OF THE WEST A PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:FAURIA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-623-4455
Mailing Address - Street 1:12660 RIVERSIDE DR STE 305
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3431
Mailing Address - Country:US
Mailing Address - Phone:818-623-4455
Mailing Address - Fax:818-985-0055
Practice Address - Street 1:18433 ROSCOE BLVD STE 214
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4123
Practice Address - Country:US
Practice Address - Phone:818-985-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88417627213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16152Medicare ID - Type Unspecified
CA4707550002Medicare NSC