Provider Demographics
NPI:1538145974
Name:NETTBOY, RICHARD MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:NETTBOY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22819 NORTH SANDLEFOOT BLVD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-3937
Mailing Address - Country:US
Mailing Address - Phone:561-482-3338
Mailing Address - Fax:561-482-8024
Practice Address - Street 1:22819 NORTH SANDLEFOOT BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-3937
Practice Address - Country:US
Practice Address - Phone:561-482-3338
Practice Address - Fax:561-482-8024
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1387213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029636800Medicaid
FL87729Medicare PIN
T55518Medicare UPIN
FL87729DMedicare PIN