Provider Demographics
NPI:1639420755
Name:OPTIMUM FOOT CARE, INC.
Entity Type:Organization
Organization Name:OPTIMUM FOOT CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JEFFRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-537-8680
Mailing Address - Street 1:1587 SILVANER AVE NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6767
Mailing Address - Country:US
Mailing Address - Phone:757-537-8680
Mailing Address - Fax:
Practice Address - Street 1:1175 CHAPMANS FORD RD
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-7763
Practice Address - Country:US
Practice Address - Phone:757-537-8680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I487779Medicare PIN