Provider Demographics
NPI:1609973858
Name:IBERIA FOOT SPECIALISTS, LLC
Entity Type:Organization
Organization Name:IBERIA FOOT SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:337-364-8878
Mailing Address - Street 1:2309 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4046
Mailing Address - Country:US
Mailing Address - Phone:337-364-8878
Mailing Address - Fax:337-364-8380
Practice Address - Street 1:2309 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4046
Practice Address - Country:US
Practice Address - Phone:337-364-8878
Practice Address - Fax:337-364-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD324R213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CM07Medicare ID - Type Unspecified
LADC9810Medicare ID - Type UnspecifiedRAILROAD