Provider Demographics
NPI:1295839512
Name:ADVANCED PODIATRIC SPECIALTY INC
Entity Type:Organization
Organization Name:ADVANCED PODIATRIC SPECIALTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAULAT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-977-6245
Mailing Address - Street 1:16519 N 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4951
Mailing Address - Country:US
Mailing Address - Phone:623-977-6245
Mailing Address - Fax:623-977-6280
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:J171/172
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3709
Practice Address - Country:US
Practice Address - Phone:623-977-6245
Practice Address - Fax:623-977-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0547261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ77222Medicare PIN
AZ5060290001Medicare NSC