Provider Demographics
NPI:1316194632
Name:CARBON FOOT AND ANKLE CENTERS PC
Entity Type:Organization
Organization Name:CARBON FOOT AND ANKLE CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-377-5544
Mailing Address - Street 1:215 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-2163
Mailing Address - Country:US
Mailing Address - Phone:610-377-5544
Mailing Address - Fax:610-377-6744
Practice Address - Street 1:215 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-2163
Practice Address - Country:US
Practice Address - Phone:610-377-5544
Practice Address - Fax:610-377-6744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004598L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022344500001Medicaid
PA6198940001Medicare NSC