Provider Demographics
NPI:1407925738
Name:PRESCOTT FOOT & ANKLE CLINIC PC
Entity Type:Organization
Organization Name:PRESCOTT FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-776-0770
Mailing Address - Street 1:919 12TH PLACE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:928-776-0770
Mailing Address - Fax:928-776-8991
Practice Address - Street 1:919 12TH PLACE
Practice Address - Street 2:SUITE 10
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:928-776-0770
Practice Address - Fax:928-776-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0261AZ213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700634Medicaid
Z69927Medicare ID - Type UnspecifiedGRP
AZ700634Medicaid
AZT42032Medicare UPIN
AZ0833580001Medicare NSC