Provider Demographics
NPI:1518082098
Name:OAKWOOD LAKES PODIATRY GROUP PA
Entity Type:Organization
Organization Name:OAKWOOD LAKES PODIATRY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-364-5522
Mailing Address - Street 1:3695 W BOYNTON BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4516
Mailing Address - Country:US
Mailing Address - Phone:561-364-5522
Mailing Address - Fax:561-364-9823
Practice Address - Street 1:3695 W BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4516
Practice Address - Country:US
Practice Address - Phone:561-364-5522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1994213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4015340001Medicare NSC