Provider Demographics
NPI:1619951613
Name:HIGHSMITH, DWAYNE LEONARD (DPM)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:LEONARD
Last Name:HIGHSMITH
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:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:707-454-5901
Practice Address - Street 1:770 MASON ST FL 2D
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688
Practice Address - Country:US
Practice Address - Phone:707-427-4900
Practice Address - Fax:707-454-5901
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3376213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33760Medicaid
CA000E33760Medicaid
000E33760Medicare PIN