Provider Demographics
NPI:1639102833
Name:ORANGE COUNTY FOOT AND ANKLE GROUP, INC.
Entity Type:Organization
Organization Name:ORANGE COUNTY FOOT AND ANKLE GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-888-6860
Mailing Address - Street 1:300 N EUCLID ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1623
Mailing Address - Country:US
Mailing Address - Phone:714-888-6860
Mailing Address - Fax:714-888-6867
Practice Address - Street 1:300 N EUCLID ST
Practice Address - Street 2:SUITE A
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1623
Practice Address - Country:US
Practice Address - Phone:714-888-6860
Practice Address - Fax:714-888-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17894Medicare UPIN
CA5369500001Medicare NSC