Provider Demographics
NPI:1598812786
Name:AMMONS, JOEL A III (DPM)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:A
Last Name:AMMONS
Suffix:III
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:PO BOX 1274
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-1274
Mailing Address - Country:US
Mailing Address - Phone:310-671-8065
Mailing Address - Fax:310-671-5810
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-671-8065
Practice Address - Fax:310-671-5810
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3561213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5537360001OtherMEDICARE DME
CAOOOE35610Medicaid
CAE3561OtherLICENSE NUMBER
CAE3561Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAT86392Medicare UPIN