Provider Demographics
NPI:1619952868
Name:THE FOOT SPECIALIST OF SULPHUR APC
Entity Type:Organization
Organization Name:THE FOOT SPECIALIST OF SULPHUR APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PESHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:337-625-7604
Mailing Address - Street 1:101 ADVENT ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-4027
Mailing Address - Country:US
Mailing Address - Phone:337-625-7604
Mailing Address - Fax:337-625-7606
Practice Address - Street 1:101 ADVENT ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-4027
Practice Address - Country:US
Practice Address - Phone:337-625-7604
Practice Address - Fax:337-625-7606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD217R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty