Provider Demographics
NPI:1588678445
Name:UNIVERSAL FOOT AND ANKLE CLINIC
Entity Type:Organization
Organization Name:UNIVERSAL FOOT AND ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-732-7551
Mailing Address - Street 1:3130 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2484
Mailing Address - Country:US
Mailing Address - Phone:323-732-7551
Mailing Address - Fax:323-732-7829
Practice Address - Street 1:3130 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2484
Practice Address - Country:US
Practice Address - Phone:323-732-7551
Practice Address - Fax:323-732-7829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4172213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41720Medicaid
U72564Medicare UPIN
CA000E41720Medicaid