Provider Demographics
NPI:1710197272
Name:SOLE FOOT AND ANKLE SPECIALISTS PC
Entity Type:Organization
Organization Name:SOLE FOOT AND ANKLE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:602-938-3600
Mailing Address - Street 1:PO BOX 27514
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-7514
Mailing Address - Country:US
Mailing Address - Phone:480-967-6500
Mailing Address - Fax:480-967-6540
Practice Address - Street 1:5750 W THUNDERBIRD RD STE G700
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4673
Practice Address - Country:US
Practice Address - Phone:602-938-3600
Practice Address - Fax:602-938-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0196213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700064Medicaid
AZZ24569Medicare PIN
AZ0633230002Medicare NSC