Provider Demographics
NPI:1679741813
Name:FAMILY FOOT HEALTH SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:FAMILY FOOT HEALTH SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARLO
Authorized Official - Middle Name:G
Authorized Official - Last Name:VANDER WILT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-843-6464
Mailing Address - Street 1:718 LOMAS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2073
Mailing Address - Country:US
Mailing Address - Phone:505-843-6464
Mailing Address - Fax:505-764-9210
Practice Address - Street 1:718 LOMAS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2073
Practice Address - Country:US
Practice Address - Phone:505-843-6464
Practice Address - Fax:505-764-9210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM099213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF8031Medicaid
NM6149810001Medicare NSC