Provider Demographics
NPI:1689108649
Name:ACACIA FOOT AND ANKLE SURGEONS, PLLC
Entity Type:Organization
Organization Name:ACACIA FOOT AND ANKLE SURGEONS, PLLC
Other - Org Name:ACACIA FOOT AND ANKLE SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAVEH
Authorized Official - Middle Name:
Authorized Official - Last Name:PANAHI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-439-2200
Mailing Address - Street 1:13760 N 93RD AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4250
Mailing Address - Country:US
Mailing Address - Phone:623-439-2200
Mailing Address - Fax:
Practice Address - Street 1:13760 N 93RD AVE STE 111
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4250
Practice Address - Country:US
Practice Address - Phone:623-439-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2020-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0793213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty