Provider Demographics
NPI:1447421904
Name:SWEETWATER FOOT CARE, PC
Entity Type:Organization
Organization Name:SWEETWATER FOOT CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUCKWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:307-362-9545
Mailing Address - Street 1:2631 FOOTHILL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4770
Mailing Address - Country:US
Mailing Address - Phone:307-362-9545
Mailing Address - Fax:307-362-9732
Practice Address - Street 1:2631 FOOTHILL BLVD STE C
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4770
Practice Address - Country:US
Practice Address - Phone:307-362-9545
Practice Address - Fax:307-362-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY119213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00577001OtherBLUE CROSS BLUE SHIELD
WY5402750001Medicare NSC